Healthcare Provider Details

I. General information

NPI: 1518036805
Provider Name (Legal Business Name): ANGELA MARIA CUEVAS RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA MARIA BLACKWELL RD, LD

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 13TH ST
GULFPORT MS
39501-2515
US

IV. Provider business mailing address

526 MOCKINGBIRD DR
LONG BEACH MS
39560-3100
US

V. Phone/Fax

Practice location:
  • Phone: 228-865-3653
  • Fax: 228-867-4139
Mailing address:
  • Phone: 228-865-3653
  • Fax: 228-867-4139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD1010
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: