Healthcare Provider Details

I. General information

NPI: 1477524494
Provider Name (Legal Business Name): ANGELA RUTH BAILEY R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 836 BOX 323
FPO AE
09636
IT

IV. Provider business mailing address

PSC 836 BOX 323
FPO AE
09636
IT

V. Phone/Fax

Practice location:
  • Phone: 11-390-9556
  • Fax:
Mailing address:
  • Phone: 11-390-9556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number407
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: