Provider Demographics
NPI:1457461790
Name:COCKRELL, CLAYTON DALE II (CRNP)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:DALE
Last Name:COCKRELL
Suffix:II
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 1:2131 MILITARY ST S
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:AL
Mailing Address - Zip Code:35570-6651
Mailing Address - Country:US
Mailing Address - Phone:205-921-5556
Mailing Address - Fax:205-921-5595
Practice Address - Street 1:2131 MILITARY ST S
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:AL
Practice Address - Zip Code:35570
Practice Address - Country:US
Practice Address - Phone:205-921-5556
Practice Address - Fax:205-921-5595
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-099596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-35921OtherBLUE CROSS PROVIDER ##
AL891012300Medicaid