Provider Demographics
NPI:1629323795
Name:BROLIN, ANGELA RENEE (ATC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:RENEE
Last Name:BROLIN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BOXWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554
Mailing Address - Country:US
Mailing Address - Phone:304-816-7462
Mailing Address - Fax:
Practice Address - Street 1:119 BOXWOOD LN
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2126
Practice Address - Country:US
Practice Address - Phone:304-816-7462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer