=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003429507
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANA DIESI CRAFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2020
-----------------------------------------------------
Last Update Date | 08/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 19TH ST S # 112
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35233-1926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-316-9823
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 WOOD DUCK DR
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70507-4935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------