Healthcare Provider Details

I. General information

NPI: 1750530820
Provider Name (Legal Business Name): ANGELA ROSE MARTY M.P.T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W PORT AU PRINCE LN
MOSCOW MILLS MO
63362-1056
US

IV. Provider business mailing address

115 W PORT AU PRINCE LN
MOSCOW MILLS MO
63362-1056
US

V. Phone/Fax

Practice location:
  • Phone: 636-366-4049
  • Fax:
Mailing address:
  • Phone: 636-366-4049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2006038816
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: