Provider Demographics
NPI:1386883718
Name:GRESHAM, ANGEL DOMINIQUE (APRN)
Entity type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:DOMINIQUE
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:DR
Other - First Name:ANGEL
Other - Middle Name:DOMINIQUE
Other - Last Name:BLAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2872 E POINT DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-4125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:308 GEORGE WASHINGTON HWY N STE 2
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23323-1852
Practice Address - Country:US
Practice Address - Phone:757-773-6130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024188654363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health