Healthcare Provider Details

I. General information

NPI: 1477003192
Provider Name (Legal Business Name): ANGELA LEE BOOTH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3632 AMERICAN WAY
CASPER WY
82604-3164
US

IV. Provider business mailing address

3632 AMERICAN WAY
CASPER WY
82604-3164
US

V. Phone/Fax

Practice location:
  • Phone: 307-234-6765
  • Fax:
Mailing address:
  • Phone: 307-234-6765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22031.1556
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: