Healthcare Provider Details

I. General information

NPI: 1609498997
Provider Name (Legal Business Name): ANGELA ISSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1658 ST VINCENTS WAY STE 210
MIDDLEBURG FL
32068-8459
US

IV. Provider business mailing address

1658 ST VINCENTS WAY STE 210
MIDDLEBURG FL
32068-8459
US

V. Phone/Fax

Practice location:
  • Phone: 904-602-4481
  • Fax: 904-602-4489
Mailing address:
  • Phone: 904-602-4481
  • Fax: 904-602-4489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME180223
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberBP10073174
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: