1265812424 NPI number — BRENDA FAYE GAVIN APRN FNP-C AG-ACNP-C

Table of content: BRENDA FAYE GAVIN APRN FNP-C AG-ACNP-C (NPI 1265812424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265812424 NPI number — BRENDA FAYE GAVIN APRN FNP-C AG-ACNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAVIN
Provider First Name:
BRENDA
Provider Middle Name:
FAYE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN FNP-C AG-ACNP-C
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:
1265812424
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7987
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:
36670-0987
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-633-0573
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MEMORIAL HOSPITAL DR STE 1A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36608-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-343-6848
Provider Business Practice Location Address Fax Number:
251-343-5708
Provider Enumeration Date:
06/03/2015

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:  1-087281 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , with the licence number: 1-087281 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LA2100X , with the licence number: R900157 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 6858582 . This is a "AETNA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 08101023 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 512-42739 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 250441 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 512-42738 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 512-42741 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1265812424 . This is a "HUMANA MILITARY" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 250364 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 250414 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1265812424 . This is a "MAGNOLIA HEALTH" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 250605 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 512-42742 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 5896052 . This is a "UHC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: A03966A . This is a "MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: Z27049 . This is a "VIVA HEALTH" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 117558000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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