Healthcare Provider Details

I. General information

NPI: 1023582467
Provider Name (Legal Business Name): ANGELIQUE MICHELLE MCKITRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11635 NORTHPARK DR STE 100
WAKE FOREST NC
27587-9350
US

IV. Provider business mailing address

11635 NORTHPARK DR STE 100
WAKE FOREST NC
27587-9350
US

V. Phone/Fax

Practice location:
  • Phone: 919-364-1172
  • Fax:
Mailing address:
  • Phone: 919-364-1172
  • Fax: 980-785-1114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-57760
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number937
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: