Provider Demographics
NPI:1821068552
Name:CUNDIFF-ROY, ANGELA YVONNE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:YVONNE
Last Name:CUNDIFF-ROY
Suffix:
Gender:F
Credentials:ARNP
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 1383
Mailing Address - Street 2:
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642-1383
Mailing Address - Country:US
Mailing Address - Phone:270-866-4357
Mailing Address - Fax:270-858-4957
Practice Address - Street 1:72 JOE T. PETTEY DR.
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642
Practice Address - Country:US
Practice Address - Phone:270-866-4357
Practice Address - Fax:270-858-4957
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2287P207R00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78001266Medicaid
KY78001266Medicaid
KYS25933Medicare UPIN