Provider Demographics
NPI:1447370002
Name:KING, ANGELA NICOLE (LMT)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:NICOLE
Last Name:KING
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 DELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-6508
Mailing Address - Country:US
Mailing Address - Phone:386-312-8553
Mailing Address - Fax:
Practice Address - Street 1:120 S PALM AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-4140
Practice Address - Country:US
Practice Address - Phone:386-325-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL32785174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCC2249OtherBLUECROSS AND BLUESHEILD