Provider Demographics
NPI:1417109422
Name:ANGOTTI, KELLY NICOLE (PA-AA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:ANGOTTI
Suffix:
Gender:F
Credentials:PA-AA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:RAHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-AA
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-851-4405
Practice Address - Street 1:1968 PEACHTREE RD., NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:404-351-1745
Practice Address - Fax:404-351-7121
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367H00000X
GA005647367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA840634444AMedicaid
GA840634444BOtherMEDICAID
GA202I978480Medicare PIN