Basic Information
| Provider Information | |||||||||
| NPI: | 1265812424 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAVIN | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | FAYE | ||||||||
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| Credential: | APRN FNP-C AG-ACNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7987 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366700987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516330573 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 MEMORIAL HOSPITAL DR STE 1A | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366081128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513436848 | ||||||||
| FaxNumber: | 2513435708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2015 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1-087281 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LG0600X | 1-087281 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2100X | R900157 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 6858582 | 01 | AL | AETNA | OTHER | 08101023 | 05 | MS | MEDICAID | 512-42739 | 01 | AL | BCBS | OTHER | 250441 | 05 | AL | MEDICAID | 512-42738 | 01 | AL | BCBS | OTHER | 512-42741 | 01 | AL | BCBS | OTHER | 1265812424 | 01 | AL | HUMANA MILITARY | OTHER | 250364 | 05 | AL | MEDICAID | 250414 | 05 | AL | MEDICAID | 1265812424 | 01 | MS | MAGNOLIA HEALTH | OTHER | 250605 | 05 | AL | MEDICAID | 512-42742 | 01 | AL | BCBS | OTHER | 5896052 | 01 | AL | UHC | OTHER | A03966A | 01 | AL | MEDICARE | OTHER | Z27049 | 01 | AL | VIVA HEALTH | OTHER |