Basic Information
| Provider Information | |||||||||
| NPI: | 1033177092 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLOCKS | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234336000 | ||||||||
| FaxNumber: | 4234336140 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 N STATE OF FRANKLIN RD | ||||||||
| Address2: | GROUND FLOOR | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234397320 | ||||||||
| FaxNumber: | 4234397343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363LF0000X | 103494 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 03/30/1972 | 01 | DATE OF BIRTH | OTHER |