Provider Demographics
NPI:1164989679
Name:FORMANIK, ANGELA (DPT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:FORMANIK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 CHESAPEAKE CV
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-1370
Mailing Address - Country:US
Mailing Address - Phone:440-251-2741
Mailing Address - Fax:
Practice Address - Street 1:7201 WADE PARK AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-2765
Practice Address - Country:US
Practice Address - Phone:216-361-6141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT017896225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist