Basic Information
| Provider Information | |||||||||
| NPI: | 1023098977 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 HOSPITAL DR. | ||||||||
| Address2: | STE 410 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312178014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787465644 | ||||||||
| FaxNumber: | 4787454849 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 HOSPITAL DR. | ||||||||
| Address2: | STE 410 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312178014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787465644 | ||||||||
| FaxNumber: | 4787454849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 12/13/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN144846 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 549669 | 01 | GA | WELLCARE | OTHER | AN1383 | 05 | SC | MEDICAID | 269333706A | 05 | GA | MEDICAID | P00819049 | 01 | GA | RAILROAD MEDICARE | OTHER | 580628385 | 01 | GA | TRICARE | OTHER |