Healthcare Provider Details

I. General information

NPI: 1205960879
Provider Name (Legal Business Name): MAURA NELSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 MEDICAL CENTER PKWY
SELMA AL
36701-6748
US

IV. Provider business mailing address

196 COUNTY ROAD 545
VALLEY GRANDE AL
36703-9085
US

V. Phone/Fax

Practice location:
  • Phone: 334-418-4105
  • Fax:
Mailing address:
  • Phone: 334-875-5612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1044598
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: