Provider Demographics
NPI:1629515937
Name:BALEZTENA, ANGELA C (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:C
Last Name:BALEZTENA
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 S HULEN ST
Mailing Address - Street 2:#1135
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4970
Mailing Address - Country:US
Mailing Address - Phone:720-236-2936
Mailing Address - Fax:
Practice Address - Street 1:4141 S HULEN ST
Practice Address - Street 2:#1135
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4970
Practice Address - Country:US
Practice Address - Phone:720-236-2936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist