Provider Demographics
NPI:1043426737
Name:LIVELY, ANGELA M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:M
Last Name:LIVELY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-962-4942
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL LN STE 100
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1993
Practice Address - Country:US
Practice Address - Phone:317-745-7310
Practice Address - Fax:317-745-7320
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
IN10000942A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical