Provider Demographics
NPI:1457447658
Name:REID, ANGELA M (RN, CNM, APNP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:REID
Suffix:
Gender:F
Credentials:RN, CNM, APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1430 HIGHWAY 96 E
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3653
Practice Address - Country:US
Practice Address - Phone:651-653-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007347367A00000X
WI148821-32367A00000X
MN202367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9649070Medicaid
WI36055400Medicaid
911019392OtherCOMMERCIAL
WA9649070OtherCHPW
WA9649070Medicaid
Q76526Medicare UPIN
WI0601 20195Medicare PIN