Provider Demographics
NPI:1376851162
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:DAJUNA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:TATOM
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:334-335-2471
Mailing Address - Street 1:15 HOSPITAL RD.
Mailing Address - Street 2:CRENSHAW CO. HEALTH DEPT
Mailing Address - City:LUVERNE
Mailing Address - State:AL
Mailing Address - Zip Code:36049
Mailing Address - Country:US
Mailing Address - Phone:334-335-2471
Mailing Address - Fax:334-335-3795
Practice Address - Street 1:15 HOSPITAL RD.
Practice Address - Street 2:CRENSHAW CO. HEALTH DEPT
Practice Address - City:LUVERNE
Practice Address - State:AL
Practice Address - Zip Code:36049
Practice Address - Country:US
Practice Address - Phone:334-335-2471
Practice Address - Fax:334-335-3795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-059257363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty