Provider Demographics
NPI:1780790386
Name:ARNOLD, ANGELA MARIE (PAC)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARIE
Last Name:ARNOLD
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 LINCOLN DRIVE
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948
Mailing Address - Country:US
Mailing Address - Phone:618-997-6800
Mailing Address - Fax:618-997-1187
Practice Address - Street 1:510 LINCOLN DRIVE
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948
Practice Address - Country:US
Practice Address - Phone:618-997-6800
Practice Address - Fax:618-997-1187
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002121363A00000X
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7210895OtherAETNA
IL137782OtherHAMP
IL3932056OtherBCBS
IL613533OtherHEALTHLINK
IL3932056OtherBCBS
IL137782OtherHAMP
IL613533OtherHEALTHLINK