Provider Demographics
NPI:1518969575
Name:STAPLETON-MACKENZIE, ANGELA KAY (MD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:KAY
Last Name:STAPLETON-MACKENZIE
Suffix:
Gender:F
Credentials:MD
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 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-376-4075
Practice Address - Street 1:400 COLONNADE DR STE 160
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-6236
Practice Address - Country:US
Practice Address - Phone:904-824-1020
Practice Address - Fax:904-390-7503
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136291207Q00000X
MO113071207Q00000X
WAMD60776458207Q00000X
FLME161192207QA0505X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205213010Medicaid
MO27472051OtherBCBS
MON23A393Medicare ID - Type Unspecified
MO27472051OtherBCBS