Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 1-036569 | AL |
NPI | 1013136290 |
---|---|
Provider Name | Mrs. Lera Dianna Marcelle Farmer |
First Address | Talladega, AL 35160-2219 |
Second Address | Talladega, AL 35160-2219 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2007 |
Last Update Date | 24/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
891017656 | (05) | AL |