Provider Demographics
NPI:1750732699
Name:ANDERSON, ANGELA LATRICE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:LATRICE
Last Name:ANDERSON
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 1:1602 HIGHWAY 104
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71602-9479
Mailing Address - Country:US
Mailing Address - Phone:870-329-4502
Mailing Address - Fax:
Practice Address - Street 1:145 W WATERMAN ST
Practice Address - Street 2:
Practice Address - City:DUMAS
Practice Address - State:AR
Practice Address - Zip Code:71639-2139
Practice Address - Country:US
Practice Address - Phone:870-382-4878
Practice Address - Fax:870-382-4895
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004789363LF0000X
TXAP136185363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily