Healthcare Provider Details

I. General information

NPI: 1679264998
Provider Name (Legal Business Name): ANGELA JUNE PRIKO RN NCM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7973 THUNDER BLVD
FORT CAMPBELL KY
42223-5531
US

IV. Provider business mailing address

15854 STATE ROUTE 49
VANLEER TN
37181-6000
US

V. Phone/Fax

Practice location:
  • Phone: 270-412-6331
  • Fax: 270-412-6802
Mailing address:
  • Phone: 931-627-9122
  • Fax: 270-412-6802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number167327
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: