Basic Information
| Provider Information | |||||||||
| NPI: | 1407090053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAYDEN | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | HEBERT | ||||||||
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| Credential: | APN-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT STE 212 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976015 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 255 ENTERPRISE BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296153530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644548120 | ||||||||
| FaxNumber: | 8644548125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2009 | ||||||||
| LastUpdateDate: | 02/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3859 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LG0600X | 3859 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | NP1947 | 05 | SC | MEDICAID |