Provider Demographics
NPI:1518155019
Name:UPDIKE, ANGELA GREGORY (CMT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:GREGORY
Last Name:UPDIKE
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 744
Mailing Address - Street 2:
Mailing Address - City:PRIEST RIVER
Mailing Address - State:ID
Mailing Address - Zip Code:83856-0744
Mailing Address - Country:US
Mailing Address - Phone:208-304-0383
Mailing Address - Fax:
Practice Address - Street 1:168 ROSEMARY LOOP # 2
Practice Address - Street 2:
Practice Address - City:PRIEST LAKE
Practice Address - State:ID
Practice Address - Zip Code:83856-5023
Practice Address - Country:US
Practice Address - Phone:208-304-0383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019006484174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist