=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104886936
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA MARIE MCDONALD FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2006
-----------------------------------------------------
Last Update Date | 07/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6104 AVENUE Q S. DRIVE
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-786-2346
-----------------------------------------------------
Fax | 806-472-3432
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3407 60TH STREET
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-786-2346
-----------------------------------------------------
Fax | 806-472-3432
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 243773
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------