Provider Demographics
NPI:1083935753
Name:CALLAHAN, ANGELA DAWN (NP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:DAWN
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:DAWN
Other - Last Name:LUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:15740 NEW HAMPSHIRE CT STE B
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4174
Practice Address - Country:US
Practice Address - Phone:239-466-8838
Practice Address - Fax:239-466-7669
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004708363L00000X
FLARNP9448794363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000852Medicaid
FL020061900Medicaid
FL020061900Medicaid