Basic Information
| Provider Information | |||||||||
| NPI: | 1790017523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WIMBERLY | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1114 PINE ST | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704479705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857073218 | ||||||||
| FaxNumber: | 6144422410 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 ANDRE ST STE 300 | ||||||||
| Address2: | YPS - CREDENTIALING | ||||||||
| City: | NEW IBERIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705632159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373649225 | ||||||||
| FaxNumber: | 3373646094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2010 | ||||||||
| LastUpdateDate: | 12/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP06028 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2135619 | 05 | LA | MEDICAID | 1790017523 | 01 | LA | BCBS LA | OTHER |