Healthcare Provider Details

I. General information

NPI: 1275842130
Provider Name (Legal Business Name): STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2010
Last Update Date: 09/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 CRAWFORD RD
PHENIX CITY AL
36867-0548
US

IV. Provider business mailing address

PO BOX 548 1850 CRAWFORD ROAD
PHENIX CITY AL
36867-0548
US

V. Phone/Fax

Practice location:
  • Phone: 334-297-0251
  • Fax: 334-291-5478
Mailing address:
  • Phone: 334-297-0251
  • Fax: 334-291-5478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number1-017420
License Number StateAL

VIII. Authorized Official

Name: JANICE R. MCINNIS
Title or Position: NURSE PRACTITIONER
Credential: C.R.N.P.
Phone: 334-297-0251