Healthcare Provider Details

I. General information

NPI: 1255588893
Provider Name (Legal Business Name): SHANDA COTNEY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANDA POWELL NP

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 MAIN ST S
WEDOWEE AL
36278-7440
US

IV. Provider business mailing address

119 AMBULANCE DR SUITE 202
CARROLLTON GA
30117-3857
US

V. Phone/Fax

Practice location:
  • Phone: 256-357-2188
  • Fax: 256-357-2023
Mailing address:
  • Phone: 770-838-8710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1072768
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: