Provider Demographics
NPI:1295874980
Name:WARREN, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WARREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:MANCHESTER SQUARE SHOPPING CTR. ROOM 212
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-0158
Mailing Address - Country:US
Mailing Address - Phone:606-598-5564
Mailing Address - Fax:606-598-6615
Practice Address - Street 1:111 N 21ST ST
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1375
Practice Address - Country:US
Practice Address - Phone:606-248-2862
Practice Address - Fax:606-248-2876
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3461P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0275811Medicare ID - Type Unspecified