Healthcare Provider Details

I. General information

NPI: 1699309666
Provider Name (Legal Business Name): ANGEL SUE SQUIRE APRN - PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 SCOTTSVILLE RD #50327
BOWLING GREEN KY
42104
US

IV. Provider business mailing address

PO BOX 50327
BOWLING GREEN KY
42102-2927
US

V. Phone/Fax

Practice location:
  • Phone: 615-813-0726
  • Fax:
Mailing address:
  • Phone: 615-813-0726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN0000027631
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF403253-01
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0027948
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3014665
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.363146
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1143292
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: