1093130205 NPI number — MRS. COURTNEY MCDANIEL NIX CRNP

Table of content: MRS. COURTNEY MCDANIEL NIX CRNP (NPI 1093130205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093130205 NPI number — MRS. COURTNEY MCDANIEL NIX CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIX
Provider First Name:
COURTNEY
Provider Middle Name:
MCDANIEL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093130205
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 850489
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36685-0489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-342-3949
Provider Business Mailing Address Fax Number:
251-631-3361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 ENNIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARALAND
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36571-2706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-544-2000
Provider Business Practice Location Address Fax Number:
251-544-2004
Provider Enumeration Date:
02/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  1-125175 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 157308 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 511-48068 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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