Healthcare Provider Details

I. General information

NPI: 1780115089
Provider Name (Legal Business Name): ANGELA COOL BEDWELL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5251 CONCOURSE DR
ROANOKE VA
24019
US

IV. Provider business mailing address

2112 BRICK CHURCH RD
ROCKY MOUNT VA
24151-4052
US

V. Phone/Fax

Practice location:
  • Phone: 540-904-2817
  • Fax: 540-682-5946
Mailing address:
  • Phone: 540-525-7020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024174641
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: