Provider Demographics
NPI:1073041505
Name:KEENUM, TYLER (CRNP)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:KEENUM
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-1731
Mailing Address - Country:US
Mailing Address - Phone:205-759-8470
Mailing Address - Fax:205-366-9001
Practice Address - Street 1:2720 6TH ST
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-1731
Practice Address - Country:US
Practice Address - Phone:205-759-8470
Practice Address - Fax:205-366-9001
Is Sole Proprietor?:No
Enumeration Date:2017-05-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-142399363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner