Provider Demographics
NPI:1417243502
Name:ANDERSON, ANGELA L (NP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 18TH STREET CIR SE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-1361
Mailing Address - Country:US
Mailing Address - Phone:828-324-4005
Mailing Address - Fax:828-315-5974
Practice Address - Street 1:250 18TH STREET CIR SE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-1361
Practice Address - Country:US
Practice Address - Phone:828-324-4005
Practice Address - Fax:828-315-5974
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005204363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1417243502Medicaid