Provider Demographics
NPI:1902247299
Name:KEECH, ANGELICA FORMO (WHNP-BC,NP-C)
Entity Type:Individual
Prefix:MRS
First Name:ANGELICA
Middle Name:FORMO
Last Name:KEECH
Suffix:
Gender:F
Credentials:WHNP-BC,NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 LOUISE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2147
Mailing Address - Country:US
Mailing Address - Phone:844-866-1866
Mailing Address - Fax:704-987-4250
Practice Address - Street 1:198 HWY 45 NORTH
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NC
Practice Address - Zip Code:27962
Practice Address - Country:US
Practice Address - Phone:252-793-3023
Practice Address - Fax:252-791-3108
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006257363LW0102X, 363LA2200X, 363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health