Healthcare Provider Details

I. General information

NPI: 1245715077
Provider Name (Legal Business Name): MISS ANGELA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2018
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33870 BLUE STAR HWY APT 1107
MIDWAY FL
32343-2434
US

IV. Provider business mailing address

33870 BLUE STAR HWY APT1107
MIDWAY FLORIDA
32343
AO

V. Phone/Fax

Practice location:
  • Phone: 850-264-1909
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number235607
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: