Provider Demographics
NPI:1841240223
Name:HUCKABEE, MARY ELLEN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:HUCKABEE
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:PO BOX 935
Mailing Address - Street 2:
Mailing Address - City:GROVE HILL
Mailing Address - State:AL
Mailing Address - Zip Code:36451-0935
Mailing Address - Country:US
Mailing Address - Phone:251-275-3173
Mailing Address - Fax:251-275-4281
Practice Address - Street 1:295B S JACKSON ST
Practice Address - Street 2:
Practice Address - City:GROVE HILL
Practice Address - State:AL
Practice Address - Zip Code:36451-3231
Practice Address - Country:US
Practice Address - Phone:251-275-3173
Practice Address - Fax:251-275-4281
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1038498363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALS21446Medicare UPIN