Provider Demographics
NPI:1619268612
Name:ANGEL KIDS PEDIATRICS
Entity Type:Organization
Organization Name:ANGEL KIDS PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:GORDEN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:904-674-2304
Mailing Address - Street 1:13241 BARTRAM PARK BLVD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5212
Mailing Address - Country:US
Mailing Address - Phone:904-674-2304
Mailing Address - Fax:904-551-1502
Practice Address - Street 1:13241 BARTRAM PARK BLVD
Practice Address - Street 2:SUITE 209
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5212
Practice Address - Country:US
Practice Address - Phone:904-674-2304
Practice Address - Fax:904-551-1502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9279833364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatricsGroup - Single Specialty