Provider Demographics
NPI:1578545067
Name:ST. ANGELO, ROSA M (PNP)
Entity Type:Individual
Prefix:MS
First Name:ROSA
Middle Name:M
Last Name:ST. ANGELO
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3499 S MERCY RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-0437
Mailing Address - Country:US
Mailing Address - Phone:480-355-8525
Mailing Address - Fax:480-355-3115
Practice Address - Street 1:3499 S MERCY RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0437
Practice Address - Country:US
Practice Address - Phone:480-355-8525
Practice Address - Fax:480-355-3115
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN071704363LP0200X
AZAP7011363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ563587Medicaid