Provider Demographics
NPI:1952787376
Name:SEVERADO, ANGELA KATHERINE (FNP-BC AND PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:KATHERINE
Last Name:SEVERADO
Suffix:
Gender:F
Credentials:FNP-BC AND PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 SHADOW RIDGE CT APT 10
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-3905
Mailing Address - Country:US
Mailing Address - Phone:217-816-7928
Mailing Address - Fax:
Practice Address - Street 1:1 JEFFERSON BARRACKS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-4181
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-07
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.001329363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL309.008660Medicaid