Provider Demographics
NPI:1316222615
Name:BACON SMITH, ANGELINA DENISE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:ANGELINA
Middle Name:DENISE
Last Name:BACON SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 NW 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33311-6457
Mailing Address - Country:US
Mailing Address - Phone:754-214-8818
Mailing Address - Fax:
Practice Address - Street 1:7710 NW 71ST CT STE 210
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2932
Practice Address - Country:US
Practice Address - Phone:954-707-3253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-18
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA58998225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist