Provider Demographics
NPI:1972156040
Name:DISON, ANGELA POTTER (NP)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:POTTER
Last Name:DISON
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PLAZA PL
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-3330
Practice Address - Country:US
Practice Address - Phone:318-377-2321
Practice Address - Fax:318-371-5606
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206722363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner