1790028975 NPI number — DR. MARY THERESE ACFALLE CALLENS CRNP

Table of content: DR. MARY THERESE ACFALLE CALLENS CRNP (NPI 1790028975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790028975 NPI number — DR. MARY THERESE ACFALLE CALLENS CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALLENS
Provider First Name:
MARY THERESE
Provider Middle Name:
ACFALLE
Provider Name Prefix Text:
DR.
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:
1790028975
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6269 KESTRAL VIEW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRUSSVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35173-6318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-975-5595
Provider Business Mailing Address Fax Number:
205-934-0655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
176 7FL RM 7301F
Provider Second Line Business Practice Location Address:
619 19TH ST S
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35249-7404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-975-5595
Provider Business Practice Location Address Fax Number:
205-934-0655
Provider Enumeration Date:
04/05/2013

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:  1-096719 , 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)





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