Provider Demographics
NPI:1275842130
Name:STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Entity Type:Organization
Organization Name:STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:334-297-0251
Mailing Address - Street 1:PO BOX 548
Mailing Address - Street 2:1850 CRAWFORD ROAD
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-0548
Mailing Address - Country:US
Mailing Address - Phone:334-297-0251
Mailing Address - Fax:334-291-5478
Practice Address - Street 1:1850 CRAWFORD RD
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-0548
Practice Address - Country:US
Practice Address - Phone:334-297-0251
Practice Address - Fax:334-291-5478
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-017420363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty