Provider Demographics
NPI:1619264835
Name:DEANGELIS, GINA MARIE (RD)
Entity Type:Individual
Prefix:MISS
First Name:GINA
Middle Name:MARIE
Last Name:DEANGELIS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39830 GRAND RIVER AVE STE B-3
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2134
Mailing Address - Country:US
Mailing Address - Phone:248-477-6100
Mailing Address - Fax:248-473-6173
Practice Address - Street 1:39830 GRAND RIVER AVE STE B-3
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2134
Practice Address - Country:US
Practice Address - Phone:248-477-6100
Practice Address - Fax:248-473-6173
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1037622133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered