Provider Demographics
NPI:1902342983
Name:SHUTLZ, JEREMY ALLEN (CRNP)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:ALLEN
Last Name:SHUTLZ
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 1:200 MEDICAL CENTER DR SW
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35968-3458
Mailing Address - Country:US
Mailing Address - Phone:256-845-3150
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL CENTER DR SW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35968-3458
Practice Address - Country:US
Practice Address - Phone:256-845-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-135341363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care