Provider Demographics
NPI:1649076472
Name:PRIDE, ANGELEA M
Entity type:Individual
Prefix:
First Name:ANGELEA
Middle Name:M
Last Name:PRIDE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 SUN PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-7837
Mailing Address - Country:US
Mailing Address - Phone:918-704-7719
Mailing Address - Fax:
Practice Address - Street 1:27 EAST ROSS AVENUE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066
Practice Address - Country:US
Practice Address - Phone:918-216-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0053808164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse