=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790117141
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELIA M MICKLE FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2013
-----------------------------------------------------
Last Update Date | 03/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4940 COTTONVILLE RD STE 100
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-675-6830
-----------------------------------------------------
Fax | 937-675-6835
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4940 COTTONVILLE RD STE 100
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45335-1522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-675-2870
-----------------------------------------------------
Fax | 937-675-2873
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.14976
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | COA.14976-NP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------