Provider Demographics
NPI:1386849677
Name:CASE-SUTPHEN, ANGELA K (PNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:K
Last Name:CASE-SUTPHEN
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7200 BRIARWYCK CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-1726
Mailing Address - Country:US
Mailing Address - Phone:972-571-4196
Mailing Address - Fax:972-571-4196
Practice Address - Street 1:12461 TIMBERLAND BLVD STE 309
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5212
Practice Address - Country:US
Practice Address - Phone:817-741-5437
Practice Address - Fax:972-571-4196
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX653122363LP0200X
TXAP111076363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174315502Medicaid
TXTXB117509Medicare PIN