Basic Information
| Provider Information | |||||||||
| NPI: | 1295196210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | BLAKEY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, ARNP, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N DEAN RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328253710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218416444 | ||||||||
| FaxNumber: | 4076501307 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N DEAN RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328253710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218416444 | ||||||||
| FaxNumber: | 4076501307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2016 | ||||||||
| LastUpdateDate: | 10/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | ARNP-9242402 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LF0000X | ARNP-9242402 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | ARNP9242402 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 018284000 | 05 | FL | MEDICAID |