Provider Demographics
NPI:1912058694
Name:KISELYK, ANGELA CHANNELLE
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:CHANNELLE
Last Name:KISELYK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 W AUBURN DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1617
Mailing Address - Country:US
Mailing Address - Phone:602-279-6282
Mailing Address - Fax:602-274-2157
Practice Address - Street 1:4530 N 32ND ST STE 104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-3357
Practice Address - Country:US
Practice Address - Phone:602-279-6282
Practice Address - Fax:602-274-2157
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3091363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical