Provider Demographics
NPI:1063825834
Name:FORD, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:FORD
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 1:311 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:SOUR LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:77659-9250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:311 PINEHURST DR
Practice Address - Street 2:
Practice Address - City:SOUR LAKE
Practice Address - State:TX
Practice Address - Zip Code:77659-9250
Practice Address - Country:US
Practice Address - Phone:903-245-6892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2048442172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker