Healthcare Provider Details

I. General information

NPI: 1063405553
Provider Name (Legal Business Name): ANGELA H SULLIVAN-BOWMAN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 01/10/2024
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 BATTLEFIELD PARKWAY
FT. OGLETHORPE GA
30742
US

IV. Provider business mailing address

2717 EAST OAKLAND AVENUE
JOHNSON CITY TN
37601-1843
US

V. Phone/Fax

Practice location:
  • Phone: 706-866-7700
  • Fax: 423-476-4487
Mailing address:
  • Phone: 423-926-2358
  • Fax: 423-926-2680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6046
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberGAA-NP000772
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: