Provider Demographics
NPI:1194105171
Name:EMMANUEL, TA-NISHA (CRNP)
Entity type:Individual
Prefix:
First Name:TA-NISHA
Middle Name:
Last Name:EMMANUEL
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 1:1722 PINE ST STE 203
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1158
Mailing Address - Country:US
Mailing Address - Phone:334-293-8736
Mailing Address - Fax:334-293-8738
Practice Address - Street 1:1722 PINE ST STE 502
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1160
Practice Address - Country:US
Practice Address - Phone:342-938-5883
Practice Address - Fax:334-293-6978
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-134653363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner