Healthcare Provider Details

I. General information

NPI: 1992071591
Provider Name (Legal Business Name): MYRA KAY MORISSETTE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1369A GEORGE WALLACE HWY
RUSSELLVILLE AL
35654-3281
US

IV. Provider business mailing address

1369A GEORGE WALLACE HWY
RUSSELLVILLE AL
35654-3281
US

V. Phone/Fax

Practice location:
  • Phone: 256-331-9700
  • Fax: 256-331-2615
Mailing address:
  • Phone: 256-331-9700
  • Fax: 256-331-2615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1129315
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: