Provider Demographics
NPI:1093300543
Name:SMITH, SHANNON BRANTLEY (CRNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:BRANTLEY
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 TOWNCENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-1833
Mailing Address - Country:US
Mailing Address - Phone:205-368-9377
Mailing Address - Fax:
Practice Address - Street 1:100 TOWNCENTER BLVD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-1833
Practice Address - Country:US
Practice Address - Phone:205-368-9377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-06
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1122796163W00000X
AL1-122796363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse