Provider Demographics
NPI:1558992156
Name:TRACKWELL, ANGELA NICOLE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:NICOLE
Last Name:TRACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6189 W JOHN L MODGLIN DR
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-9363
Mailing Address - Country:US
Mailing Address - Phone:317-435-1575
Mailing Address - Fax:
Practice Address - Street 1:6189 W JOHN L MODGLIN DR
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-9363
Practice Address - Country:US
Practice Address - Phone:317-866-7320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-01
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009743A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily