Provider Demographics
NPI:1255397501
Name:KELLEY, ANGELA WHITE (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:WHITE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-9792
Mailing Address - Country:US
Mailing Address - Phone:352-527-6888
Mailing Address - Fax:352-527-8818
Practice Address - Street 1:1990 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-9792
Practice Address - Country:US
Practice Address - Phone:352-527-6888
Practice Address - Fax:352-527-6888
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000001010363AM0700X
FLPA9105288363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3663478Medicaid
TN3663478Medicare ID - Type Unspecified
TN3663478Medicaid