Provider Demographics
NPI:1417121377
Name:SUTHRAVE, ANGELA WANG (RD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:WANG
Last Name:SUTHRAVE
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8130 RANDOLPH WAY
Mailing Address - Street 2:404
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4833
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8130 RANDOLPH WAY
Practice Address - Street 2:#404
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4833
Practice Address - Country:US
Practice Address - Phone:317-414-7671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered