Provider Demographics
NPI:1497222871
Name:ANGELINA, KIMBERLY NICOLE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:ANGELINA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 FAIRMOUNT AVE # R12
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2036
Mailing Address - Country:US
Mailing Address - Phone:610-360-0306
Mailing Address - Fax:
Practice Address - Street 1:10800 KNIGHTS RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-4200
Practice Address - Country:US
Practice Address - Phone:215-612-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060319363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant