Provider Demographics
NPI:1356409528
Name:TATUM, ANGELA LEANNE (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:LEANNE
Last Name:TATUM
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4147 STRAIGHT GUT RD
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728-6749
Mailing Address - Country:US
Mailing Address - Phone:706-764-2951
Mailing Address - Fax:706-764-2951
Practice Address - Street 1:4147 STRAIGHT GUT RD
Practice Address - Street 2:
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-6749
Practice Address - Country:US
Practice Address - Phone:706-764-2951
Practice Address - Fax:706-764-2951
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT002912225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4109529OtherBCBS TN
GA00740275BMedicaid
10052428OtherAMERIGROUP
339895OtherWELLCARE
4109529OtherBCBS TN