Provider Demographics
NPI:1992381164
Name:BAIN, JEANNIE LEANN (CRNP)
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:LEANN
Last Name:BAIN
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 1:180 GALA ST
Mailing Address - Street 2:
Mailing Address - City:RAINSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35986-4477
Mailing Address - Country:US
Mailing Address - Phone:256-996-9371
Mailing Address - Fax:
Practice Address - Street 1:1359 OLD WATER WORKS RD SW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35968-3347
Practice Address - Country:US
Practice Address - Phone:256-997-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-094402363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL9521OtherRX
AL1-094402OtherNP LICENSE