Provider Demographics
NPI:1619409224
Name:DERAAD, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:DERAAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LUCRETTIA
Other - Middle Name:ANGELIQUE NICOLETTE
Other - Last Name:FRANKLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:1175 CASCADE PKWY SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-3090
Mailing Address - Country:US
Mailing Address - Phone:706-415-2862
Mailing Address - Fax:
Practice Address - Street 1:1175 CASCADE PKWY SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-3090
Practice Address - Country:US
Practice Address - Phone:706-415-2862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-02
Last Update Date:2017-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAL-16676163WL0100X
GA129675163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant