Healthcare Provider Details

I. General information

NPI: 1144729286
Provider Name (Legal Business Name): ANGELA DAWN PROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E MAIN ST STE C
PAYSON AZ
85541-5488
US

IV. Provider business mailing address

126 E MAIN ST STE C
PAYSON AZ
85541-5488
US

V. Phone/Fax

Practice location:
  • Phone: 928-471-3445
  • Fax: 928-471-1015
Mailing address:
  • Phone: 928-471-3445
  • Fax: 928-471-1015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number2652
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: