Provider Demographics
NPI:1649612771
Name:ANGEL, BLAIR NICOLE (FNP)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:NICOLE
Last Name:ANGEL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:PANA
Mailing Address - State:IL
Mailing Address - Zip Code:62557-1716
Mailing Address - Country:US
Mailing Address - Phone:217-562-6246
Mailing Address - Fax:217-562-6288
Practice Address - Street 1:101 E 9TH ST
Practice Address - Street 2:
Practice Address - City:PANA
Practice Address - State:IL
Practice Address - Zip Code:62557-1716
Practice Address - Country:US
Practice Address - Phone:217-562-6246
Practice Address - Fax:217-562-6288
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041354011363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily