Provider Demographics
NPI:1295376176
Name:ZAVALA, ANGEL PHILLIP
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:PHILLIP
Last Name:ZAVALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7412 COLF RD
Mailing Address - Street 2:
Mailing Address - City:CARLETON
Mailing Address - State:MI
Mailing Address - Zip Code:48117-9136
Mailing Address - Country:US
Mailing Address - Phone:734-733-8980
Mailing Address - Fax:
Practice Address - Street 1:7412 COLF RD
Practice Address - Street 2:
Practice Address - City:CARLETON
Practice Address - State:MI
Practice Address - Zip Code:48117-9136
Practice Address - Country:US
Practice Address - Phone:734-733-8980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703111925164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse