Provider Demographics
NPI:1609344423
Name:DILLICK, ANGELA MARIE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:DILLICK
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 1:900 MULLANPHY RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-3231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:294 KINGS RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-6330
Practice Address - Country:US
Practice Address - Phone:618-975-3781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO28361A376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide