=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881211043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATALIE JAYNE ELLISON CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2020
-----------------------------------------------------
Last Update Date | 07/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2030 LAY DAM RD
-----------------------------------------------------
City | CLANTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35045-8344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-258-4405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11705 COUNTY ROAD 29
-----------------------------------------------------
City | CLANTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35045-7839
-----------------------------------------------------
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 | 1-148424
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------