Provider Demographics
NPI:1891122362
Name:BALLAS, ANGELA FARAH (APRN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:FARAH
Last Name:BALLAS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 HATCHETTS HILL RD
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-1534
Mailing Address - Country:US
Mailing Address - Phone:800-370-3651
Mailing Address - Fax:
Practice Address - Street 1:55 HATCHETTS HILL RD
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-1534
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005514363LP0808X
CT5514363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health