Provider Demographics
NPI:1205425873
Name:TOMLIN, CLARISSA JANE
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:JANE
Last Name:TOMLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6582 BOLL WEEVIL CIR
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-9424
Mailing Address - Country:US
Mailing Address - Phone:334-347-2027
Mailing Address - Fax:
Practice Address - Street 1:6582 BOLL WEEVIL CIR
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-9424
Practice Address - Country:US
Practice Address - Phone:334-347-2027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-148343363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily