Provider Demographics
NPI:1619183340
Name:BREWER, ANGELA MARIE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARIE
Last Name:BREWER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MRS
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:SPAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 WARD STREET EXT W
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-1902
Mailing Address - Country:US
Mailing Address - Phone:912-384-1477
Mailing Address - Fax:912-384-1470
Practice Address - Street 1:2010 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2230
Practice Address - Country:US
Practice Address - Phone:912-384-2500
Practice Address - Fax:912-383-6788
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN101667363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA715148338AMedicaid
GA11D0941435OtherCLIA ID
GA385393OtherWELLCARE OF GEORGIA
GARN10167OtherGEORGIA LICENSE
GA715148338AMedicaid
GA511I500574Medicare PIN