Healthcare Provider Details

I. General information

NPI: 1912558065
Provider Name (Legal Business Name): ANGELA RENEE MCMICHAEL AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 CHURCH ST NE
MARIETTA GA
30060-1101
US

IV. Provider business mailing address

2965 KALEY DR NW
KENNESAW GA
30152-2687
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-1372
  • Fax:
Mailing address:
  • Phone: 770-743-9526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberRN216352
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: