Healthcare Provider Details

I. General information

NPI: 1528599602
Provider Name (Legal Business Name): ANGELETTE NICHOL SYKES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10651 CALI CV
OLIVE BRANCH MS
38654-9551
US

IV. Provider business mailing address

10651 CALI CV
OLIVE BRANCH MS
38654-9551
US

V. Phone/Fax

Practice location:
  • Phone: 901-210-3294
  • Fax:
Mailing address:
  • Phone: 901-210-3294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22429
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901751
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: