=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316590482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WESLEY BRYAN DRIVER NP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2019
-----------------------------------------------------
Last Update Date | 07/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1440 NARROW LANE PKWY
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36111-2654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-281-4140
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 MAPLEWOOD DR
-----------------------------------------------------
City | CLANTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35045-2497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-462-2436
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1-143909
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------