Provider Demographics
NPI:1104041086
Name:PALACIOS, ANGELA
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
Last Name:PALACIOS
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 1:9061 WOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-6404
Mailing Address - Country:US
Mailing Address - Phone:818-894-7343
Mailing Address - Fax:
Practice Address - Street 1:9061 WOODMAN AVE
Practice Address - Street 2:
Practice Address - City:ARLETA
Practice Address - State:CA
Practice Address - Zip Code:91331-6404
Practice Address - Country:US
Practice Address - Phone:818-894-7343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD6180156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician