Healthcare Provider Details

I. General information

NPI: 1255776902
Provider Name (Legal Business Name): ANGELA E. COCHRAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA E. KELLY

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6635 LAKE DR
MORROW GA
30260-2354
US

IV. Provider business mailing address

6635 LAKE DR
MORROW GA
30260-2354
US

V. Phone/Fax

Practice location:
  • Phone: 770-968-1323
  • Fax: 770-968-4556
Mailing address:
  • Phone: 770-968-1323
  • Fax: 770-968-4556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN119943
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN119943NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: