Basic Information
| Provider Information | |||||||||
| NPI: | 1508836297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICKELTON | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | DRAUGHON | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26595 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274156595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368327786 | ||||||||
| FaxNumber: | 3362724063 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 N ELAM AVE | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274031118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368320900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 367500000X | 51813 | IL | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 144978 | NC | X | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 8051451 | 05 | NC | MEDICAID |