Provider Demographics
NPI:1134672223
Name:RICHARDSON, S ANGELA R
Entity Type:Individual
Prefix:
First Name:S ANGELA
Middle Name:R
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MOUNT ZION RD
Mailing Address - Street 2:
Mailing Address - City:LEOMA
Mailing Address - State:TN
Mailing Address - Zip Code:38468-5523
Mailing Address - Country:US
Mailing Address - Phone:931-556-2224
Mailing Address - Fax:
Practice Address - Street 1:1202 S JAMES CAMPBELL BLVD STE 7A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-5358
Practice Address - Country:US
Practice Address - Phone:931-381-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN83818164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse