Provider Demographics
NPI:1619093838
Name:PAULY, ANGELA MARY (OTR)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARY
Last Name:PAULY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 GASTON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-7046
Mailing Address - Country:US
Mailing Address - Phone:903-293-3338
Mailing Address - Fax:
Practice Address - Street 1:83 AIRWAYS PL
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5885
Practice Address - Country:US
Practice Address - Phone:662-349-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1109174400000X
TX107497174400000X
MSOT2488174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145182721Medicaid