Healthcare Provider Details

I. General information

NPI: 1932538709
Provider Name (Legal Business Name): ANGELA LIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 11/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12920 SHAFER RD
LICKING MO
65542-9413
US

IV. Provider business mailing address

12920 SHAFER RD
LICKING MO
65542-9413
US

V. Phone/Fax

Practice location:
  • Phone: 417-260-4160
  • Fax:
Mailing address:
  • Phone: 417-260-4160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number127669
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: