Basic Information
| Provider Information | |||||||||
| NPI: | 1407884356 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ATKINSON | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CFNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ATKINSON | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CFNP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012273255 | ||||||||
| FaxNumber: | 9012278591 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 HIGHWAY 16 E | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012671470 | ||||||||
| FaxNumber: | 6012671469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R855944 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0123601 | 05 | MS | MEDICAID |