Provider Demographics
NPI:1689896078
Name:ANGELO, KATHRYN LANE (DC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LANE
Last Name:ANGELO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 DOWNER AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-1115
Mailing Address - Country:US
Mailing Address - Phone:781-740-2286
Mailing Address - Fax:781-740-8214
Practice Address - Street 1:20 DOWNER AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043-1115
Practice Address - Country:US
Practice Address - Phone:781-740-2286
Practice Address - Fax:781-740-8214
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1186111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY35894OtherBLUECROSSBLUESHIELD
MA1608126Medicaid
MA1608126Medicaid