Provider Demographics
NPI:1013642099
Name:JAMES, ANGEL DAWN
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:DAWN
Last Name:JAMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 SEVILLE RD APT 216
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-1027
Mailing Address - Country:US
Mailing Address - Phone:330-461-7655
Mailing Address - Fax:
Practice Address - Street 1:455 SEVILLE RD APT 216
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-1027
Practice Address - Country:US
Practice Address - Phone:330-461-7655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.003307175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPS.003307Medicaid