Provider Demographics
NPI:1114425865
Name:SHELINE, ANGELA R
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:R
Last Name:SHELINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 MIDDLE URBANA RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-9285
Mailing Address - Country:US
Mailing Address - Phone:937-399-7777
Mailing Address - Fax:937-399-6794
Practice Address - Street 1:2717 MIAMISBURG CENTERVILLE RD STE 211
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-3704
Practice Address - Country:US
Practice Address - Phone:937-350-6700
Practice Address - Fax:937-716-2375
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021959363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0380554Medicaid