Healthcare Provider Details

I. General information

NPI: 1770784191
Provider Name (Legal Business Name): ANGELA RENEE LIPSCOMB-HUDSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA RENEE LIPSCOMB

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4207 LAKE BOONE TRL STE 210
RALEIGH NC
27607-6685
US

IV. Provider business mailing address

4207 LAKE BOONE TRL
RALEIGH NC
27607-6684
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-7874
  • Fax:
Mailing address:
  • Phone: 614-214-6029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number125054432
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2011-00898
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: