Provider Demographics
NPI:1619298320
Name:PRATT, ANGELA MICHELLE (LMT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MICHELLE
Last Name:PRATT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:PEYTA
Other - Middle Name:ANGELA
Other - Last Name:PRATT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:3600 CEDAR FLAT RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMS
Mailing Address - State:OR
Mailing Address - Zip Code:97544-9682
Mailing Address - Country:US
Mailing Address - Phone:541-787-1104
Mailing Address - Fax:
Practice Address - Street 1:3600 CEDAR FLAT RD
Practice Address - Street 2:
Practice Address - City:WILLIAMS
Practice Address - State:OR
Practice Address - Zip Code:97544-9682
Practice Address - Country:US
Practice Address - Phone:541-787-1104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16444225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist