Provider Demographics
NPI:1548534266
Name:POULOS, ANGELA ROSE (NP-C)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:ROSE
Last Name:POULOS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 W PARK LN
Mailing Address - Street 2:
Mailing Address - City:KOHLER
Mailing Address - State:WI
Mailing Address - Zip Code:53044-1451
Mailing Address - Country:US
Mailing Address - Phone:906-370-7242
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:920-547-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-27
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4782-33363LF0000X
MI4704176645363LF0000X
MNR124766-8363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily