Basic Information
| Provider Information | |||||||||
| NPI: | 1922570118 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITCHELL-MATTHEWS | ||||||||
| FirstName: | ANGERENE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 626 AUTUMN OAKS LOOP | ||||||||
| Address2: | |||||||||
| City: | WINTER GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347872011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1267206064 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4901 LANG AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058428171 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2018 | ||||||||
| LastUpdateDate: | 06/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11000742 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 58573 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 46102329 | 05 | NM | MEDICAID |