Provider Demographics
NPI:1144796673
Name:SOUTHERN NEONATAL NURSE PRACTITIONERS, LLC
Entity Type:Organization
Organization Name:SOUTHERN NEONATAL NURSE PRACTITIONERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/CRNP
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:205-531-2755
Mailing Address - Street 1:8524 HAYES RD
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:AL
Mailing Address - Zip Code:35022-7926
Mailing Address - Country:US
Mailing Address - Phone:205-531-2755
Mailing Address - Fax:205-565-7939
Practice Address - Street 1:995 9TH AVE SW
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35022-4527
Practice Address - Country:US
Practice Address - Phone:205-531-2755
Practice Address - Fax:205-565-7939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL111EP1111XMedicaid
AL363L00000XMedicaid