Basic Information
Provider Information | |||||||||
NPI: | 1942258272 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FORD | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | DAWN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEPREAST | ||||||||
OtherFirstName: | ANGELA | ||||||||
OtherMiddleName: | DAWN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1869 | ||||||||
Address2: |   | ||||||||
City: | FLETCHER | ||||||||
State: | NC | ||||||||
PostalCode: | 287321869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286875616 | ||||||||
FaxNumber: | 8286508076 | ||||||||
Practice Location | |||||||||
Address1: | 436 AIRPORT ROAD | ||||||||
Address2: |   | ||||||||
City: | ARDEN | ||||||||
State: | NC | ||||||||
PostalCode: | 28704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286507282 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2006 | ||||||||
LastUpdateDate: | 01/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | ARNP1742912 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LF0000X | 5013540 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 82127 | 01 | FL | BCBS | OTHER | 300864900 | 05 | FL |   | MEDICAID | 593736126 | 01 | FL | AETNA | OTHER |