Provider Demographics
NPI:1710518527
Name:GOMES DOS SANTOS, ANGELA (IBCLC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:GOMES DOS SANTOS
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 E LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-2111
Mailing Address - Country:US
Mailing Address - Phone:704-622-3785
Mailing Address - Fax:
Practice Address - Street 1:3911 MARY ELIZA TRCE NW STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1088
Practice Address - Country:US
Practice Address - Phone:678-384-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-162040174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN