Healthcare Provider Details

I. General information

NPI: 1144094228
Provider Name (Legal Business Name): ANGELA GAYLE WOOD RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 S LANCASTER RD
DALLAS TX
75216-7167
US

IV. Provider business mailing address

2106 J J PEARCE DR
RICHARDSON TX
75081-5448
US

V. Phone/Fax

Practice location:
  • Phone: 214-742-8387
  • Fax:
Mailing address:
  • Phone: 817-454-2969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDT0466
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: