Healthcare Provider Details

I. General information

NPI: 1851744213
Provider Name (Legal Business Name): ANGELICA TRIEU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10828 HIGHWAY 57
VANCLEAVE MS
39565-8264
US

IV. Provider business mailing address

14500 PINE RIDGE RD
OCEAN SPRINGS MS
39565-7807
US

V. Phone/Fax

Practice location:
  • Phone: 228-826-4711
  • Fax:
Mailing address:
  • Phone: 504-495-9087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number901484
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: