Provider Demographics
NPI:1730646084
Name:BURKHALTER, ANGELA BROOKE (PA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:BROOKE
Last Name:BURKHALTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 BUTLER MILL RD
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-3320
Mailing Address - Country:US
Mailing Address - Phone:502-319-5333
Mailing Address - Fax:
Practice Address - Street 1:120 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-5287
Practice Address - Country:US
Practice Address - Phone:865-475-4742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant