Provider Demographics
NPI:1578562096
Name:STEPHENS, CHARLES RANDALL (CRNP)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:RANDALL
Last Name:STEPHENS
Suffix:
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 1:129 LOCKERBIE LN
Mailing Address - Street 2:
Mailing Address - City:DORA
Mailing Address - State:AL
Mailing Address - Zip Code:35062-4466
Mailing Address - Country:US
Mailing Address - Phone:205-901-8850
Mailing Address - Fax:
Practice Address - Street 1:1190 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SUMITON
Practice Address - State:AL
Practice Address - Zip Code:35148
Practice Address - Country:US
Practice Address - Phone:205-648-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0082474363LF0000X
AL1-072559363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK9772559Medicaid
OK9772559Medicaid