MEDICARE: CHARLEEN ANGELL APRN-P

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2081234405	UT

General Provider Information

NPI Number	:	1942221486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLEEN ANGELL APRN-P

Provider Business Mailing Address
First Line	:	500 FOOTHILL DR
Second Line	:	#16
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84148-0128
Country	:	US
Telephone Number	:	801-582-1565
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 FOOTHILL DR
Second Line	:	#16
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84148-0128
Country	:	US
Telephone Number	:	801-582-1565
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	12/19/2013

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