Provider Demographics
NPI:1407103229
Name:COMSTOCK, ANGELLE
Entity Type:Individual
Prefix:
First Name:ANGELLE
Middle Name:
Last Name:COMSTOCK
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 1:3900 E 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-8925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 E 16TH AVE STE B
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-8925
Practice Address - Country:US
Practice Address - Phone:208-819-9934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID589769-10174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist