Provider Demographics
NPI:1508808197
Name:RUTAN, ANGELA L (CNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:RUTAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:L
Other - Last Name:RUTAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNP
Mailing Address - Street 1:110 DOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2231 TIMBER TRL
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-9036
Practice Address - Country:US
Practice Address - Phone:937-599-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.06501363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
341407259OtherTRICARE
OH341407259OtherAETNA
OH2285469Medicaid
341407259OtherCIGNA
P41451Medicare UPIN
RUNP08914Medicare ID - Type Unspecified