Provider Demographics
NPI:1316390743
Name:TEJADA, ANGELIQUE MARIE
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:MARIE
Last Name:TEJADA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LAKEWIND TRL
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5407
Mailing Address - Country:US
Mailing Address - Phone:770-355-1029
Mailing Address - Fax:
Practice Address - Street 1:100 LAKEWIND TRL
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5407
Practice Address - Country:US
Practice Address - Phone:770-355-1029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL46182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer