=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407363146
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYSON SCOTT RAINER FNP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2018
-----------------------------------------------------
Last Update Date | 01/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 MCCURDY AVE S STE C
-----------------------------------------------------
City | RAINSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35986-5206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-638-8513
-----------------------------------------------------
Fax | 256-638-8533
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2420
-----------------------------------------------------
City | RAINSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35986-2420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-638-8513
-----------------------------------------------------
Fax | 256-638-8533
-----------------------------------------------------
=====================================================
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 | F01180190
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------