=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093448649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEART OF AN ANGEL HOME CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2022
-----------------------------------------------------
Last Update Date | 07/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1313 MEMPHIS ST SE # 1313
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24013-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-892-9563
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1313 MEMPHIS ST SE
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24013-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-892-9653
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LPN
-----------------------------------------------------
Name | SIERRA BROWN
-----------------------------------------------------
Credential | LPN
-----------------------------------------------------
Telephone | 540-892-9653
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------