Provider Demographics
NPI:1558877472
Name:STOVALL-AMOS, ANGELINA
Entity Type:Individual
Prefix:
First Name:ANGELINA
Middle Name:
Last Name:STOVALL-AMOS
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 OLD CHENEY ROAD
Mailing Address - Street 2:STE 201 #324
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-2709
Mailing Address - Country:US
Mailing Address - Phone:402-413-8932
Mailing Address - Fax:
Practice Address - Street 1:3640 SW 16TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68522-9206
Practice Address - Country:US
Practice Address - Phone:402-413-8932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1032771133V00000X, 133VN1004X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic