Provider Demographics
NPI:1538589601
Name:THOMAS, ANGELA BLAKE (FNP-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:BLAKE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4905
Mailing Address - Country:US
Mailing Address - Phone:662-377-7150
Mailing Address - Fax:662-377-7155
Practice Address - Street 1:710 HIGHWAY 371
Practice Address - Street 2:710 HWY. 371
Practice Address - City:MOOREVILLE
Practice Address - State:MS
Practice Address - Zip Code:38857-7356
Practice Address - Country:US
Practice Address - Phone:662-840-4577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR879736363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03228399Medicaid