Provider Demographics
NPI:1750051058
Name:TUTTLE, ANGELICA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:TUTTLE
Suffix:
Gender:F
Credentials:PA-C
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 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:624 MAYSVILLE RD
Practice Address - Street 2:
Practice Address - City:MOUNT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-9767
Practice Address - Country:US
Practice Address - Phone:859-497-4144
Practice Address - Fax:859-497-4137
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2911363A00000X
KYTC098363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100778350Medicaid