Provider Demographics
NPI:1063446326
Name:PERRY, ANGELA (NP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31598-0100
Mailing Address - Country:US
Mailing Address - Phone:912-427-2045
Mailing Address - Fax:912-427-5880
Practice Address - Street 1:240 PEACHTREE ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0212
Practice Address - Country:US
Practice Address - Phone:912-427-2045
Practice Address - Fax:912-427-5880
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN058023163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBJFWMedicare ID - Type UnspecifiedTOOMBS HD
GA50BBDBSMedicare ID - Type UnspecifiedCOFFEE HD
GAS89408Medicare UPIN
GA50BBDBTMedicare ID - Type UnspecifiedBACON HD
GA50BBDBRMedicare ID - Type UnspecifiedWAYNE HD