Healthcare Provider Details

I. General information

NPI: 1104243401
Provider Name (Legal Business Name): ANGIE MARIE BAKER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3123 N KY HIGHWAY 15 STE 1
HAZARD KY
41701-5632
US

IV. Provider business mailing address

3123 N KY HIGHWAY 15 STE 1
HAZARD KY
41701-5632
US

V. Phone/Fax

Practice location:
  • Phone: 606-439-3399
  • Fax: 606-487-9280
Mailing address:
  • Phone: 606-439-3399
  • Fax: 606-487-9280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberKY-5082
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: