Provider Demographics
NPI:1710599204
Name:TABOH, ANGELINE NGWE (NP)
Entity Type:Individual
Prefix:MS
First Name:ANGELINE
Middle Name:NGWE
Last Name:TABOH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2944 MARCO DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8724
Mailing Address - Country:US
Mailing Address - Phone:678-778-5438
Mailing Address - Fax:
Practice Address - Street 1:2944 MARCO DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-8724
Practice Address - Country:US
Practice Address - Phone:678-778-5438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020026237208D00000X, 363LP0808X, 364SP0808X
TX1033098208D00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health