MEDICARE: ANGELA M PRIDGEON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	373H00000X	Day Training/Habilitation Specialist

General Provider Information

NPI Number	:	1104804517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA M PRIDGEON

Provider Business Mailing Address
First Line	:	7026 VIDA LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32222-1785
Country	:	US
Telephone Number	:	904-573-0727
Fax Number	:

Provider Business Practice Location Address
First Line	:	7026 VIDA LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32222-1785
Country	:	US
Telephone Number	:	904-573-0727
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	07/08/2007

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