Provider Demographics
NPI:1003312257
Name:DANFORTH, ANGELA SHERRELL
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:SHERRELL
Last Name:DANFORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 JIMMY LEE SMITH PARKWAY SUITE 104 #346
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2853
Mailing Address - Country:US
Mailing Address - Phone:470-616-0086
Mailing Address - Fax:213-319-6947
Practice Address - Street 1:5220 JIMMY LEE SMITH PARKWAY SUITE 104 #346
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2853
Practice Address - Country:US
Practice Address - Phone:470-616-0086
Practice Address - Fax:213-319-6947
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN247888163W00000X, 363LF0000X, 363LP0808X
NY837214-01363LF0000X
WA61246611363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily