=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235807900
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA M STANLEY NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2021
-----------------------------------------------------
Last Update Date | 08/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 612 ROXBURY RD
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-5089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-227-8331
-----------------------------------------------------
Fax | 855-243-0207
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 607 S SHABBONA RD
-----------------------------------------------------
City | SHABBONA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60550-9785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-739-7309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 209.023268
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------