Provider Demographics
NPI:1790117141
Name:MICKLE, ANGELIA M (FNP)
Entity Type:Individual
Prefix:
First Name:ANGELIA
Middle Name:M
Last Name:MICKLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ANGELIA
Other - Middle Name:M
Other - Last Name:MAINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4940 COTTONVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45335-1522
Mailing Address - Country:US
Mailing Address - Phone:937-675-2870
Mailing Address - Fax:937-675-2873
Practice Address - Street 1:4940 COTTONVILLE RD
Practice Address - Street 2:STE 100
Practice Address - City:JAMESTOWN
Practice Address - State:OH
Practice Address - Zip Code:45335
Practice Address - Country:US
Practice Address - Phone:937-675-6830
Practice Address - Fax:937-675-6835
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.14976363LP0808X
OHCOA.14976-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0095517Medicaid
OHH254070Medicare PIN