Provider Demographics
NPI:1114690039
Name:EASON, ANGELIA MICHELE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:ANGELIA
Middle Name:MICHELE
Last Name:EASON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1668 W PEACE ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-5332
Mailing Address - Country:US
Mailing Address - Phone:601-859-5213
Mailing Address - Fax:
Practice Address - Street 1:283 W RACE ST
Practice Address - Street 2:
Practice Address - City:ROLLING FORK
Practice Address - State:MS
Practice Address - Zip Code:39159-2621
Practice Address - Country:US
Practice Address - Phone:662-873-0477
Practice Address - Fax:662-655-1236
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine