Provider Demographics
NPI:1679787139
Name:SMITH, ANGELA MARIA (LPN)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:MARIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BYESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43723-1002
Mailing Address - Country:US
Mailing Address - Phone:740-685-3668
Mailing Address - Fax:740-685-3668
Practice Address - Street 1:808 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43713-1042
Practice Address - Country:US
Practice Address - Phone:740-425-3987
Practice Address - Fax:740-425-3987
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN079683164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2231258Medicaid