Provider Demographics
NPI:1710477922
Name:LANDRUM, ANGLIEA SHENELL
Entity Type:Individual
Prefix:
First Name:ANGLIEA
Middle Name:SHENELL
Last Name:LANDRUM
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 1:85 DEADY AVE
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-1003
Mailing Address - Country:US
Mailing Address - Phone:617-516-7994
Mailing Address - Fax:
Practice Address - Street 1:85 DEADY AVE
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-1003
Practice Address - Country:US
Practice Address - Phone:617-516-7994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21106681224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist