Healthcare Provider Details

I. General information

NPI: 1225454507
Provider Name (Legal Business Name): ANGELA RENEE BOONE NP ADULT GERIATRIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 THOMPSON ST
EDEN NC
27288-5045
US

IV. Provider business mailing address

405 THOMPSON ST
EDEN NC
27288-5045
US

V. Phone/Fax

Practice location:
  • Phone: 336-627-4896
  • Fax: 336-627-0139
Mailing address:
  • Phone: 336-627-4896
  • Fax: 336-627-0139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5006739
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number5006739
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: