Provider Demographics
NPI:1659343903
Name:DECLUE, ANGELA S (FNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:S
Last Name:DECLUE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:S
Other - Last Name:HUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 HEALTH WAY DR
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-1434
Mailing Address - Country:US
Mailing Address - Phone:573-438-2977
Mailing Address - Fax:573-438-2874
Practice Address - Street 1:200 HEALTH WAY DR
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1434
Practice Address - Country:US
Practice Address - Phone:573-438-2977
Practice Address - Fax:573-438-2874
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO132460363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428971402Medicaid
MO818952288Medicare ID - Type UnspecifiedMISSOURI MEDICARE