Provider Demographics
NPI:1912217902
Name:THOMAS, ANGELA BUCKLES (APRN)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:BUCKLES
Last Name:THOMAS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 N DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2521
Mailing Address - Country:US
Mailing Address - Phone:270-737-0678
Mailing Address - Fax:
Practice Address - Street 1:1009 N DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2521
Practice Address - Country:US
Practice Address - Phone:270-737-0678
Practice Address - Fax:270-769-1535
Is Sole Proprietor?:No
Enumeration Date:2010-10-08
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6666S364SA2200X
KY3006666363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6666SOtherARNP REGISTRATION NUMBER
KY7100270530Medicaid
KY6666SOtherARNP REGISTRATION NUMBER
KYK037521Medicare PIN