1255875167 NPI number — ANGELLA E HENRY NURSE PRACTITIONER

Table of content: ANGELLA E HENRY NURSE PRACTITIONER (NPI 1255875167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255875167 NPI number — ANGELLA E HENRY NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENRY
Provider First Name:
ANGELLA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255875167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
433 BAYWOOD WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIRAM
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30141-4125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-417-7066
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 QUARTZ DR STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VILLA RICA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30180-3256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-812-3839
Provider Business Practice Location Address Fax Number:
770-456-3785
Provider Enumeration Date:
12/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN171201 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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