Provider Demographics
NPI:1780215699
Name:ANGELES, KATHERINE RAE (NP)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:RAE
Last Name:ANGELES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:ANGELES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11524 CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3954
Mailing Address - Country:US
Mailing Address - Phone:909-725-4288
Mailing Address - Fax:
Practice Address - Street 1:1720 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-1727
Practice Address - Country:US
Practice Address - Phone:909-796-6915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015701363LP0200X
CA818775163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics