Healthcare Provider Details

I. General information

NPI: 1588053045
Provider Name (Legal Business Name): MS. JESSICA RAE ANGEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4109 ADAMS ST
HOLLYWOOD FL
33021-7366
US

IV. Provider business mailing address

4109 ADAMS ST
HOLLYWOOD FL
33021-7366
US

V. Phone/Fax

Practice location:
  • Phone: 954-295-2190
  • Fax:
Mailing address:
  • Phone: 954-295-2190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9302274
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: