Provider Demographics
NPI:1326899147
Name:GADDY, ANGELO
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:
Last Name:GADDY
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 1:1100 WILDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-5080
Mailing Address - Country:US
Mailing Address - Phone:313-671-4738
Mailing Address - Fax:
Practice Address - Street 1:16540 WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2964
Practice Address - Country:US
Practice Address - Phone:313-671-4738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide