Provider Demographics
NPI:1609125202
Name:OUTLAW, JERRY LADON (CRNP)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LADON
Last Name:OUTLAW
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 1:145 KATHERINE AVE.
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360-1987
Mailing Address - Country:US
Mailing Address - Phone:334-774-5116
Mailing Address - Fax:334-774-6848
Practice Address - Street 1:145 KATHERINE AVE.
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-1987
Practice Address - Country:US
Practice Address - Phone:334-774-5116
Practice Address - Fax:334-774-6848
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-070149363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily