Healthcare Provider Details

I. General information

NPI: 1083148092
Provider Name (Legal Business Name): ANGELA LYNN VANNORTWICK N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 US HIGHWAY 41 N
TIFTON GA
31794-2749
US

IV. Provider business mailing address

907 18TH ST E STE 400
TIFTON GA
31794-3684
US

V. Phone/Fax

Practice location:
  • Phone: 229-391-3320
  • Fax: 229-391-3325
Mailing address:
  • Phone: 229-353-3422
  • Fax: 229-353-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN127277
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: