Healthcare Provider Details

I. General information

NPI: 1790275337
Provider Name (Legal Business Name): ANGELIQUE CROWDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGIE SKYHH

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 HIGHLAND AVE NE
ATLANTA GA
30312-1375
US

IV. Provider business mailing address

780 MOROSGO DR NE UNIT 13571
ATLANTA GA
30324-0571
US

V. Phone/Fax

Practice location:
  • Phone: 404-797-9778
  • Fax:
Mailing address:
  • Phone: 404-797-9778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCO111160
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: