Provider Demographics
NPI:1700241791
Name:HYDE, ANGIE (LPN)
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:HYDE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:HYDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:323 ROLAND RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-5336
Mailing Address - Country:US
Mailing Address - Phone:706-253-1112
Mailing Address - Fax:706-253-1120
Practice Address - Street 1:1401 APPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2699
Practice Address - Country:US
Practice Address - Phone:706-270-5033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN066910164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse