Provider Demographics
NPI:1629464136
Name:DOTSON, ANGELIA
Entity Type:Individual
Prefix:
First Name:ANGELIA
Middle Name:
Last Name:DOTSON
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:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62202-0304
Mailing Address - Country:US
Mailing Address - Phone:618-606-3734
Mailing Address - Fax:
Practice Address - Street 1:210 S CHURCH ST
Practice Address - Street 2:APT 2A
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-2266
Practice Address - Country:US
Practice Address - Phone:618-606-3734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1504015372500000X, 372600000X, 374U00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide