Provider Demographics
NPI:1134215361
Name:BIRDSONG FELLOWS, ANGELA (NP)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
Last Name:BIRDSONG FELLOWS
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:PO BOX 16435
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61132-6435
Mailing Address - Country:US
Mailing Address - Phone:318-212-3520
Mailing Address - Fax:
Practice Address - Street 1:1666 E BERT KOUN LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5714
Practice Address - Country:US
Practice Address - Phone:318-212-3520
Practice Address - Fax:318-212-3965
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04997363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPENDINGMedicare UPIN