Provider Demographics
NPI:1952681074
Name:ANGELRAY FAMILY MEDICAL LLC
Entity Type:Organization
Organization Name:ANGELRAY FAMILY MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:O'DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, CRNP
Authorized Official - Phone:570-590-2573
Mailing Address - Street 1:215 W CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:MAHANOY CITY
Mailing Address - State:PA
Mailing Address - Zip Code:17948-2505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 W CENTRE ST
Practice Address - Street 2:
Practice Address - City:MAHANOY CITY
Practice Address - State:PA
Practice Address - Zip Code:17948-2505
Practice Address - Country:US
Practice Address - Phone:570-590-2573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009671261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021574590001Medicaid
PA1104094291OtherINDIVIDUAL PROVIDER NPI
PA11974651OtherCAQH PROVIDER ID
PA152756UGYMedicare PIN