Healthcare Provider Details

I. General information

NPI: 1063478550
Provider Name (Legal Business Name): ANGELA SHADE ISOM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5744 NANJACK CIR
MEMPHIS TN
38115-2061
US

IV. Provider business mailing address

601 N WALNUT BEND RD
CORDOVA TN
38018-6494
US

V. Phone/Fax

Practice location:
  • Phone: 901-797-9711
  • Fax: 901-797-9771
Mailing address:
  • Phone: 901-751-8482
  • Fax: 901-758-2089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number82822
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: