Provider Demographics
NPI:1699862474
Name:DURHAM, ANGELA PRUITT (NP)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:PRUITT
Last Name:DURHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1958 SAXON VALLEY CIR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-6007
Mailing Address - Country:US
Mailing Address - Phone:404-417-0176
Mailing Address - Fax:
Practice Address - Street 1:1800 HOWELL MILL RD NW
Practice Address - Street 2:SUITE 800
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-2538
Practice Address - Country:US
Practice Address - Phone:404-350-9853
Practice Address - Fax:404-350-8407
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN180719NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51046579DUROtherBCBS PROVIDER NUMBER
ALDU000046579Medicaid
ALS85027Medicare UPIN
AL000046579DURMedicare ID - Type UnspecifiedPROVIDER NUMBER