Provider Demographics
NPI:1083198725
Name:BAKER, ANGELINE PETTIT (RDN, LDN, LPN)
Entity Type:Individual
Prefix:
First Name:ANGELINE
Middle Name:PETTIT
Last Name:BAKER
Suffix:
Gender:F
Credentials:RDN, LDN, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 COOK RD
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3231
Mailing Address - Country:US
Mailing Address - Phone:318-243-7699
Mailing Address - Fax:
Practice Address - Street 1:2560 COOK RD
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3231
Practice Address - Country:US
Practice Address - Phone:318-243-7699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2950133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered