Provider Demographics
NPI:1609209766
Name:JAGOUTZ, ANGELA (NP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:JAGOUTZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BRICKHILL AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-1999
Mailing Address - Country:US
Mailing Address - Phone:207-773-1728
Mailing Address - Fax:
Practice Address - Street 1:5 BUCKNAM RD
Practice Address - Street 2:SUITE 1D
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-1392
Practice Address - Country:US
Practice Address - Phone:207-781-1551
Practice Address - Fax:207-781-1552
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP131068363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner