=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881211019
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAQUALYN TAITE CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2020
-----------------------------------------------------
Last Update Date | 03/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4005 N COLLEGE AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36545-2024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-744-6084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 306491
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37230-6491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 1-150563
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------