Healthcare Provider Details

I. General information

NPI: 1922292895
Provider Name (Legal Business Name): ANGELA R FORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 SIMMONS ST
MARYVILLE TN
37801-4750
US

IV. Provider business mailing address

6800 BAUM DR BUILDING 1
KNOXVILLE TN
37919-7315
US

V. Phone/Fax

Practice location:
  • Phone: 865-374-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number54543
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: