Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 71009148 | IN |
NPI | 1003473307 |
---|---|
Provider Name | Angela Booth |
First Address | Fort Wayne, IN 46845-1703 |
Second Address | Fort Wayne, IN 46845-1701 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/05/2019 |
Last Update Date | 29/08/2019 |