Provider Demographics
NPI:1104121730
Name:RIDDLE, ANGELA MAE (APRN)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MAE
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 84068
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073-0002
Mailing Address - Country:US
Mailing Address - Phone:803-699-9073
Mailing Address - Fax:866-527-0937
Practice Address - Street 1:335 PLEASANT POINT DR
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29907-1164
Practice Address - Country:US
Practice Address - Phone:803-699-9073
Practice Address - Fax:866-527-0937
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2013-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4425363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1857Medicaid
SCAA5980Medicare PIN