Healthcare Provider Details

I. General information

NPI: 1346711082
Provider Name (Legal Business Name): TOMMY VIRGIL MCCLUSKEY CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16023 HIGHWAY 72
ROGERSVILLE AL
35652-8141
US

IV. Provider business mailing address

16023 HIGHWAY 72
ROGERSVILLE AL
35652-8141
US

V. Phone/Fax

Practice location:
  • Phone: 256-247-0093
  • Fax:
Mailing address:
  • Phone: 256-247-0093
  • Fax: 256-247-7018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-134865
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: