Provider Demographics
NPI:1972024453
Name:PERIDES, ANGELA MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:PERIDES
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 1:49 WILD ROSE DR
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9468
Mailing Address - Country:US
Mailing Address - Phone:719-371-4248
Mailing Address - Fax:
Practice Address - Street 1:3676 PARKER BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2212
Practice Address - Country:US
Practice Address - Phone:719-553-2200
Practice Address - Fax:719-553-2216
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2022-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106696363L00000X
COAPN.0995502-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner