Provider Demographics
NPI:1235415803
Name:LACEY, ANGELA KATHERINE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:KATHERINE
Last Name:LACEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:BLAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 764
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:NH
Mailing Address - Zip Code:03748-0764
Mailing Address - Country:US
Mailing Address - Phone:603-306-1648
Mailing Address - Fax:603-410-0191
Practice Address - Street 1:6 ALFANO DR
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:NH
Practice Address - Zip Code:03748-3828
Practice Address - Country:US
Practice Address - Phone:603-306-1648
Practice Address - Fax:603-410-0191
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3032225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3104639Medicaid