Provider Demographics
NPI:1376306217
Name:ANDERSON, ANGEL GENINE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:GENINE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15592 PONCHA SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4972
Mailing Address - Country:US
Mailing Address - Phone:951-218-6719
Mailing Address - Fax:
Practice Address - Street 1:15592 PONCHA SPRINGS WAY
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4972
Practice Address - Country:US
Practice Address - Phone:951-218-6719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028906363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily