Provider Demographics
NPI:1588634745
Name:MITCHELL, ANGELA R (FNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:R
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 MEMORIAL DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-6196
Mailing Address - Country:US
Mailing Address - Phone:606-598-5104
Mailing Address - Fax:606-598-0983
Practice Address - Street 1:509 MEMORIAL DR STE 2
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-6196
Practice Address - Country:US
Practice Address - Phone:606-598-4538
Practice Address - Fax:606-599-2528
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004210363LF0000X
KY3819P363LF0000X
KY3003819363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78008133Medicaid
NC7004259Medicaid
11386486OtherCAQH ID
SCNP1343Medicaid
KYMM1525089OtherDEA