Healthcare Provider Details

I. General information

NPI: 1235443573
Provider Name (Legal Business Name): ANGELA PORVAZNIK R.D., L.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 E STATE ST
ATHENS OH
45701-2138
US

IV. Provider business mailing address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

V. Phone/Fax

Practice location:
  • Phone: 740-589-3100
  • Fax: 740-589-3123
Mailing address:
  • Phone: 740-441-1949
  • Fax: 740-446-5982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD.1948
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: