=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497129159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNAIL REESE FORT CERTIFIED HAIR LOSS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2015
-----------------------------------------------------
Last Update Date | 11/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3009B MCGEHEE RD
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36111-2202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-280-3930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3009B MCGEHEE RD
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36111-2202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-280-3930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 59208
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------