Provider Demographics
NPI:1790017523
Name:DAVIS, ANGELA C (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:C
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:C
Other - Last Name:WIMBERLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1114 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-9705
Mailing Address - Country:US
Mailing Address - Phone:985-707-3218
Mailing Address - Fax:614-442-2410
Practice Address - Street 1:1100 ANDRE ST STE 300
Practice Address - Street 2:YPS - CREDENTIALING
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2159
Practice Address - Country:US
Practice Address - Phone:337-364-9225
Practice Address - Fax:337-364-6094
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06028367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2135619Medicaid
LA1790017523OtherBCBS LA
LA1790017523OtherBCBS LA