Provider Demographics
NPI:1316657778
Name:ANDERSON, ANGELA RENE (MSN, APRN, NNP-BC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:RENE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MSN, APRN, NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2298
Mailing Address - Country:US
Mailing Address - Phone:779-696-4425
Mailing Address - Fax:
Practice Address - Street 1:1401 E. STATE ST.
Practice Address - Street 2:61104
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104
Practice Address - Country:US
Practice Address - Phone:779-696-4425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-28
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15195-33363LN0000X
IL209026401363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal