Basic Information
| Provider Information | |||||||||
| NPI: | 1588829139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DODGE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 47222 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672017222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162688131 | ||||||||
| FaxNumber: | 3162914788 | ||||||||
| Practice Location | |||||||||
| Address1: | 929 N SAINT FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162685775 | ||||||||
| FaxNumber: | 3162917496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 11/30/2010 | ||||||||
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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 | 363L00000X | 46215 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163W00000X | 139521322 | KS | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 200567260A | 05 | KS | MEDICAID | 110990010 | 01 | KS | MEDICARE | OTHER |