Provider Demographics
NPI:1629252846
Name:TOLLESON, ANGELLA (CNP)
Entity Type:Individual
Prefix:MRS
First Name:ANGELLA
Middle Name:
Last Name:TOLLESON
Suffix:
Gender:F
Credentials:CNP
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 689
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0689
Mailing Address - Country:US
Mailing Address - Phone:918-647-8635
Mailing Address - Fax:918-635-3191
Practice Address - Street 1:105 WALL ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4433
Practice Address - Country:US
Practice Address - Phone:918-647-8635
Practice Address - Fax:918-635-3191
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK77294363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200372080BMedicaid
OKCNP77294OtherCNP77294