Provider Demographics
NPI:1043939291
Name:WEISS, ANGELA MICHELLE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MICHELLE
Last Name:WEISS
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 1:5020 BOULDER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-1205
Mailing Address - Country:US
Mailing Address - Phone:913-449-3682
Mailing Address - Fax:
Practice Address - Street 1:5020 BOULDER LAKE RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-1205
Practice Address - Country:US
Practice Address - Phone:913-449-3682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86192133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered