Provider Demographics
NPI:1952074189
Name:CORREA, ANGELICA MANZOLILLO (FNP-C)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MANZOLILLO
Last Name:CORREA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 SE TIFFANY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1651 SE TIFFANY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7564
Practice Address - Country:US
Practice Address - Phone:772-398-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-25
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF347464-01363LP2300X
FL11031122363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care