Provider Demographics
NPI:1558793653
Name:BALLOU, ANGELA DAWN (OTR/L)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:DAWN
Last Name:BALLOU
Suffix:
Gender:F
Credentials:OTR/L
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 8633
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95155-8633
Mailing Address - Country:US
Mailing Address - Phone:408-722-8629
Mailing Address - Fax:
Practice Address - Street 1:1052 DELNA MANOR LN
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3457
Practice Address - Country:US
Practice Address - Phone:408-722-8629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5802174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist