Provider Demographics
NPI:1053563601
Name:NIX, ANGELA NICOLE (PT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:NICOLE
Last Name:NIX
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:NICOLE
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:724 BEAVERS RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-6138
Mailing Address - Country:US
Mailing Address - Phone:404-247-0174
Mailing Address - Fax:
Practice Address - Street 1:724 BEAVERS RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-6138
Practice Address - Country:US
Practice Address - Phone:404-247-0174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0084042251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I650397OtherMEDICARE PTAN