Provider Demographics
NPI:1790275337
Name:CROWDER, ANGELIQUE
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:
Last Name:CROWDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:
Other - Last Name:SKYHH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:780 MOROSGO DR NE UNIT 13571
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-0571
Mailing Address - Country:US
Mailing Address - Phone:404-797-9778
Mailing Address - Fax:
Practice Address - Street 1:375 HIGHLAND AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1375
Practice Address - Country:US
Practice Address - Phone:404-797-9778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO111160224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist