Provider Demographics
NPI:1316570518
Name:WHITESIDE, ANGELA NICHOLE
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:NICHOLE
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 FAIRWAYS LOOKOUT APT A
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-1104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1306 FAIRWAYS LOOKOUT APT A
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1104
Practice Address - Country:US
Practice Address - Phone:410-688-7513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-16
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant