Provider Demographics
NPI:1588829139
Name:DODGE, ANGELA L (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:L
Last Name:DODGE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 47222
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-7222
Mailing Address - Country:US
Mailing Address - Phone:316-268-8131
Mailing Address - Fax:316-291-4788
Practice Address - Street 1:929 N SAINT FRANCIS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3821
Practice Address - Country:US
Practice Address - Phone:316-268-5775
Practice Address - Fax:316-291-7496
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS46215363L00000X
KS139521322163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200567260AMedicaid
KS110990010OtherMEDICARE