MEDICARE: MISTY DAWN ANGEL

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	246Z00000X	Other Specialist/Technologist

General Provider Information

NPI Number	:	1750135810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY DAWN ANGEL

Provider Business Mailing Address
First Line	:	1522 OAKHURST DR
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25314-6100
Country	:	US
Telephone Number	:	407-982-4876
Fax Number	:	407-650-2758

Provider Business Practice Location Address
First Line	:	1522 OAKHURST DR
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25314-2442
Country	:	US
Telephone Number	:	304-601-3803
Fax Number	:

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

Provider Enumeration Date	:	04/15/2024
Last Update Date	:	04/24/2026

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Directions to “ MISTY DAWN ANGEL ” Practice Location

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