Provider Demographics
NPI:1063235075
Name:ERVIN, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:ERVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 OLD 41 HWY NW # 112-206
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4480
Mailing Address - Country:US
Mailing Address - Phone:470-460-8322
Mailing Address - Fax:
Practice Address - Street 1:1635 OLD 41 HWY NW STE 112-206
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4480
Practice Address - Country:US
Practice Address - Phone:470-460-8322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty