Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 1-136281 | AL |
NPI | 1003206301 |
---|---|
Provider Name | Kayla Clemons |
First Address | Mobile, AL 36689-6144 |
Second Address | Mobile, AL 36608-3143 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/01/2015 |
Last Update Date | 09/08/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
176035 | (05) | AL |
511-60221 | BCBS OF AL (01) | |
P01499103 | RR MEDICARE (01) | |
Z98006 | VIVA (01) |