=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568347573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMMA DE ANGELO APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2025
-----------------------------------------------------
Last Update Date | 08/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3560 A1A S
-----------------------------------------------------
City | SAINT AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32080-9731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-584-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 349 VARNER WAY
-----------------------------------------------------
City | SAINT AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32092-3374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-746-0563
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11041543
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------