1962637843 NPI number — ANGELA BROWNE WELTY ACNP-BC

Table of content: ANGELA BROWNE WELTY ACNP-BC (NPI 1962637843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962637843 NPI number — ANGELA BROWNE WELTY ACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELTY
Provider First Name:
ANGELA
Provider Middle Name:
BROWNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ACNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BREWER
Provider Other First Name:
ANGELA
Provider Other Middle Name:
CHRISTINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN, ACNP-BC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962637843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 HIGHWAY 90
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAUTIER
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39553-5340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-497-7576
Provider Business Mailing Address Fax Number:
228-497-8869

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2809 DENNY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASCAGOULA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39581-5301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-809-5510
Provider Business Practice Location Address Fax Number:
228-809-5519
Provider Enumeration Date:
05/21/2009

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: 363LA2100X , with the licence number:  903471 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08655393 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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