Provider Demographics
NPI:1235443573
Name:PORVAZNIK, ANGELA (RD, LD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:PORVAZNIK
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-441-1949
Mailing Address - Fax:740-446-5982
Practice Address - Street 1:2131 E STATE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2138
Practice Address - Country:US
Practice Address - Phone:740-589-3100
Practice Address - Fax:740-589-3123
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.1948133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMT04651Medicare PIN