Healthcare Provider Details

I. General information

NPI: 1326864711
Provider Name (Legal Business Name): REESE ELIZABETH GWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 PAXTON PL
VESTAVIA AL
35242-7468
US

IV. Provider business mailing address

4230 PAXTON PL
VESTAVIA AL
35242-7468
US

V. Phone/Fax

Practice location:
  • Phone: 205-968-7391
  • Fax:
Mailing address:
  • Phone: 205-968-7391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-195930
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: