Provider Demographics
NPI:1609523471
Name:LEGGETT, ANGELA LYNN
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LYNN
Last Name:LEGGETT
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 1:1114 HUNT CLUB LN
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-5121
Mailing Address - Country:US
Mailing Address - Phone:813-789-3643
Mailing Address - Fax:
Practice Address - Street 1:1114 HUNT CLUB LN
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-5121
Practice Address - Country:US
Practice Address - Phone:813-789-3643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9256688363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9256688Medicaid