Provider Demographics
NPI:1902122591
Name:SWANSON, AUDREY PHILLIPS (CRNP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:PHILLIPS
Last Name:SWANSON
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 1:3160 W MAIN ST STE 6
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1180
Mailing Address - Country:US
Mailing Address - Phone:334-678-9123
Mailing Address - Fax:
Practice Address - Street 1:3160 W MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1180
Practice Address - Country:US
Practice Address - Phone:334-678-9123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALA0310068363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALA0310068OtherCERTIFIED NURSE PRACTITIONER NUMBER