Healthcare Provider Details

I. General information

NPI: 1902668577
Provider Name (Legal Business Name): DEMARIS DOROUGH GREENE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 CHAFFEE ST
TALLADEGA AL
35160-2809
US

IV. Provider business mailing address

1050 CLEAR CREEK DR
ALPINE AL
35014-6084
US

V. Phone/Fax

Practice location:
  • Phone: 256-362-4197
  • Fax:
Mailing address:
  • Phone: 205-705-6331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-177827
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: