Provider Demographics
NPI:1164632519
Name:GROSS, ANGELA (RD)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 CHADWICK CT
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-6504
Mailing Address - Country:US
Mailing Address - Phone:423-847-0603
Mailing Address - Fax:
Practice Address - Street 1:921 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2102
Practice Address - Country:US
Practice Address - Phone:423-209-8229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN710395133V00000X
251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Not Answered251K00000XAgenciesPublic Health or Welfare