Provider Demographics
NPI:1033506324
Name:CORCORAN, ANGELA (MS, RDN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 BLACKSMITH DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2072
Mailing Address - Country:US
Mailing Address - Phone:860-301-3806
Mailing Address - Fax:
Practice Address - Street 1:3 FARM GLEN BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1981
Practice Address - Country:US
Practice Address - Phone:860-284-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03-175723133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered