Provider Demographics
NPI:1174105431
Name:FRESH AESTHETICS MEDICAL SPA
Entity type:Organization
Organization Name:FRESH AESTHETICS MEDICAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NP-C
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:STANGER
Authorized Official - Suffix:
Authorized Official - Credentials:AGPCNP
Authorized Official - Phone:208-358-3637
Mailing Address - Street 1:1411 FALLS AVE E STE 105
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:208-358-3637
Mailing Address - Fax:
Practice Address - Street 1:1411 FALLS AVE E STE 105
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3455
Practice Address - Country:US
Practice Address - Phone:208-358-3637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty