Healthcare Provider Details

I. General information

NPI: 1063825834
Provider Name (Legal Business Name): ANGELA FORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 PINEHURST DR
SOUR LAKE TX
77659-9250
US

IV. Provider business mailing address

311 PINEHURST DR
SOUR LAKE TX
77659-9250
US

V. Phone/Fax

Practice location:
  • Phone: 903-245-6892
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number2048442
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: