Provider Demographics
NPI:1265548986
Name:HERNDON, ANGELA DAWN (APN)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:DAWN
Last Name:HERNDON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 NORTH PLUM STREET
Mailing Address - Street 2:
Mailing Address - City:BREESE
Mailing Address - State:IL
Mailing Address - Zip Code:62230-9998
Mailing Address - Country:US
Mailing Address - Phone:618-526-4700
Mailing Address - Fax:618-566-7121
Practice Address - Street 1:397 NORTH PLUM STREET
Practice Address - Street 2:
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230-9998
Practice Address - Country:US
Practice Address - Phone:618-526-4700
Practice Address - Fax:618-566-7121
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041328145363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23789Medicare UPIN
IL382430Medicare ID - Type Unspecified