Provider Demographics
NPI:1942221486
Name:ANGELL, CHARLEEN (APRN-P)
Entity type:Individual
Prefix:
First Name:CHARLEEN
Middle Name:
Last Name:ANGELL
Suffix:
Gender:F
Credentials:APRN-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 FOOTHILL DR
Mailing Address - Street 2:#16
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84148-0128
Mailing Address - Country:US
Mailing Address - Phone:801-582-1565
Mailing Address - Fax:
Practice Address - Street 1:500 FOOTHILL DR
Practice Address - Street 2:#16
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0128
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2081234405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005767404Medicare PIN