Healthcare Provider Details

I. General information

NPI: 1619709078
Provider Name (Legal Business Name): ANGELICA ANDERSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2024
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 VILLAGE WAY
LEBANON KY
40033-1845
US

IV. Provider business mailing address

546 CLELL MATTINGLY RD
RAYWICK KY
40060-7573
US

V. Phone/Fax

Practice location:
  • Phone: 731-394-1145
  • Fax:
Mailing address:
  • Phone: 270-295-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4026321
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4026321
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: