Healthcare Provider Details

I. General information

NPI: 1457966376
Provider Name (Legal Business Name): ANGELA M KEHLENBRINK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA M SHEARON PA

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-2088
  • Fax: 208-381-2893
Mailing address:
  • Phone:
  • Fax: 317-777-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3771758
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003079A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: