Healthcare Provider Details

I. General information

NPI: 1477137826
Provider Name (Legal Business Name): MS. AMY MICHELLE NULL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 COUNTY HIGHWAY 84
PHIL CAMPBELL AL
35581-6509
US

IV. Provider business mailing address

7542 SULPHUR SPRINGS RD
RAMER TN
38367-5425
US

V. Phone/Fax

Practice location:
  • Phone: 256-627-4032
  • Fax:
Mailing address:
  • Phone: 731-610-0424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number18-60970
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: