Provider Demographics
NPI:1962097527
Name:LIPSCOMB, MYRA BETHANY (CRNP)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:BETHANY
Last Name:LIPSCOMB
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 1:5529 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903-4863
Mailing Address - Country:US
Mailing Address - Phone:256-393-3838
Mailing Address - Fax:
Practice Address - Street 1:1007 GOODYEAR AVE
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903-1195
Practice Address - Country:US
Practice Address - Phone:256-393-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-146861363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty