Healthcare Provider Details

I. General information

NPI: 1205337102
Provider Name (Legal Business Name): ANGELA TAVOLACCI BSNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. ANGELA WATTS

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 02/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5914 WESTCHESTER ST
ALEXANDRIA VA
22310-1139
US

IV. Provider business mailing address

5914 WESTCHESTER ST
ALEXANDRIA VA
22310-1139
US

V. Phone/Fax

Practice location:
  • Phone: 269-277-3795
  • Fax:
Mailing address:
  • Phone: 269-277-3795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: