Healthcare Provider Details

I. General information

NPI: 1255875167
Provider Name (Legal Business Name): ANGELLA E HENRY NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 QUARTZ DR STE 201
VILLA RICA GA
30180-3256
US

IV. Provider business mailing address

433 BAYWOOD WAY
HIRAM GA
30141-4125
US

V. Phone/Fax

Practice location:
  • Phone: 770-812-3839
  • Fax: 770-456-3785
Mailing address:
  • Phone: 770-818-9150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP171201
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: