Provider Demographics
NPI:1124017611
Name:HAYES-BOUCHER, ANGELA (DO)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:
Last Name:HAYES-BOUCHER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 JOHNSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5657
Mailing Address - Country:US
Mailing Address - Phone:708-354-7417
Mailing Address - Fax:678-401-6672
Practice Address - Street 1:3120 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5657
Practice Address - Country:US
Practice Address - Phone:770-835-4741
Practice Address - Fax:678-401-6672
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA257244396FMedicaid