Provider Demographics
NPI:1578253175
Name:TABB, ANGELICA LYNN
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:LYNN
Last Name:TABB
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 1:1394 MILFORD CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:LEARY
Mailing Address - State:GA
Mailing Address - Zip Code:39862-7518
Mailing Address - Country:US
Mailing Address - Phone:229-809-0810
Mailing Address - Fax:
Practice Address - Street 1:104 CENTURY RD E STE C
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-4463
Practice Address - Country:US
Practice Address - Phone:229-809-0810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA088000002174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty