Provider Demographics
NPI:1457966376
Name:KEHLENBRINK, ANGELA M (PA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:KEHLENBRINK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:SHEARON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 778912
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8912
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-274-4779
Practice Address - Fax:317-948-9806
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003079A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300046601Medicaid