Provider Demographics
NPI:1659563203
Name:GORAZD, ANGELA JOY (DNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:JOY
Last Name:GORAZD
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:618-463-7777
Mailing Address - Fax:618-463-7767
Practice Address - Street 1:4 MEMORIAL DR STE 230B
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6751
Practice Address - Country:US
Practice Address - Phone:618-463-7777
Practice Address - Fax:618-463-7767
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-004483363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097885Medicaid
IL209004483Medicaid
IL209004483Medicaid
IL036097885Medicaid