Provider Demographics
NPI:1922570118
Name:MITCHELL-MATTHEWS, ANGERENE (FNP)
Entity Type:Individual
Prefix:
First Name:ANGERENE
Middle Name:
Last Name:MITCHELL-MATTHEWS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 AUTUMN OAKS LOOP
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-2011
Mailing Address - Country:US
Mailing Address - Phone:126-720-6064
Mailing Address - Fax:
Practice Address - Street 1:4901 LANG AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4495
Practice Address - Country:US
Practice Address - Phone:505-842-8171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11000742363LF0000X
NM58573363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM46102329Medicaid