Basic Information
Provider Information | |||||||||
NPI: | 1679058614 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | CHRISTINA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEGGETT | ||||||||
OtherFirstName: | ANGELA | ||||||||
OtherMiddleName: | CHRISTINA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 192 CAMDALE CT | ||||||||
Address2: |   | ||||||||
City: | MCDONOUGH | ||||||||
State: | GA | ||||||||
PostalCode: | 302522305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787770450 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 657 HEMLOCK ST STE 220 | ||||||||
Address2: |   | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312018311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787417241 | ||||||||
FaxNumber: | 4787458932 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2018 | ||||||||
LastUpdateDate: | 11/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 11081 | CT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | RN185946 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.