Individual
MRS. MARY JANE SMITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNP
Taxonomy
Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
Primary
1-112783
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
245903
—
AL
05
—
246049
—
AL
05
—
248711
—
AL
01
—
A871121V
MEDICARE PTAN
AL
01
—
P02453396
RAILROAD MEDICARE
AL
Enumeration date
08/05/2019
Last updated
10/27/2021
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