Basic Information
| Provider Information | |||||||||
| NPI: | 1255776902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COCHRAN | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KELLY | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | E. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6635 LAKE DR | ||||||||
| Address2: | |||||||||
| City: | MORROW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302602354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709681323 | ||||||||
| FaxNumber: | 7709684556 | ||||||||
| Practice Location | |||||||||
| Address1: | 6635 LAKE DR | ||||||||
| Address2: | |||||||||
| City: | MORROW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302602354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709681323 | ||||||||
| FaxNumber: | 7709684556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2013 | ||||||||
| LastUpdateDate: | 10/11/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN119943 | GA | N | Nursing Service Providers | Registered Nurse | 363L00000X | RN119943NP | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 003148111A | 05 | GA | MEDICAID | 003148111B | 05 | GA | MEDICAID |