=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043076805
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA PHAN APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2024
-----------------------------------------------------
Last Update Date | 08/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4122 NW 128TH TER
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32606-4800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-792-9995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 817 NW 56TH TER STE B
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32605-6401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-234-3050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APRN11022205
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------