Provider Demographics
NPI:1467704429
Name:BOULWARE, ANGEL BROWN (FNP-C)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:BROWN
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 BOTANICAL CIR NW
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:GA
Mailing Address - Zip Code:30620-4732
Mailing Address - Country:US
Mailing Address - Phone:770-266-0181
Mailing Address - Fax:
Practice Address - Street 1:2112 BOTANICAL CIR NW
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:GA
Practice Address - Zip Code:30620-4732
Practice Address - Country:US
Practice Address - Phone:770-266-0181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN172317363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily