Provider Demographics
NPI:1275142358
Name:TATOM, ANGELA L (NP-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:TATOM
Suffix:
Gender:F
Credentials:NP-C
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11945 SAN JOSE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-396-4893
Practice Address - Street 1:724 W 19TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4101
Practice Address - Country:US
Practice Address - Phone:850-769-0278
Practice Address - Fax:850-769-6202
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL11007905207Q00000X
FLAPRN11007905363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty