Provider Demographics
NPI:1609114198
Name:PUTMAN, THERESA DARLENE (CRNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:DARLENE
Last Name:PUTMAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 4TH AVE SW STE A
Mailing Address - Street 2:
Mailing Address - City:REFORM
Mailing Address - State:AL
Mailing Address - Zip Code:35481-8018
Mailing Address - Country:US
Mailing Address - Phone:205-375-6251
Mailing Address - Fax:
Practice Address - Street 1:108 4TH AVE SW STE A
Practice Address - Street 2:
Practice Address - City:REFORM
Practice Address - State:AL
Practice Address - Zip Code:35481-8018
Practice Address - Country:US
Practice Address - Phone:205-375-6251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-074182363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner