Provider Demographics
NPI:1093863433
Name:BALLOU, ANGELES L (FNP)
Entity Type:Individual
Prefix:
First Name:ANGELES
Middle Name:L
Last Name:BALLOU
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NBHC NAS MERIDIAN
Mailing Address - Street 2:1801 FULLER ROAD BLDG 367
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39309-0001
Mailing Address - Country:US
Mailing Address - Phone:601-679-2210
Mailing Address - Fax:601-679-3232
Practice Address - Street 1:444 W FORT ST FL 2
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4535
Practice Address - Country:US
Practice Address - Phone:208-422-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-112187363LF0000X
MSR854737363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPENDINGMedicaid
PENDINGMedicare ID - Type Unspecified
PENDINGMedicare UPIN