MEDICARE: TAILA FAWN CUSTRED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	1125678	AL

General Provider Information

NPI Number	:	1447050679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAILA FAWN CUSTRED

Provider Business Mailing Address
First Line	:	4718 CEDAR LAKE RD
Second Line	:
City	:	PARRISH
State	:	AL
Zip	:	35580-6130
Country	:	US
Telephone Number	:	205-388-8254
Fax Number	:

Provider Business Practice Location Address
First Line	:	4718 CEDAR LAKE RD
Second Line	:
City	:	PARRISH
State	:	AL
Zip	:	35580-6130
Country	:	US
Telephone Number	:	205-388-8254
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2025
Last Update Date	:	03/17/2025

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Directions to “ TAILA FAWN CUSTRED ” Practice Location

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