Provider Demographics
NPI:1750507018
Name:BOTTORFF, ANGELA DAWN
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:DAWN
Last Name:BOTTORFF
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ANGELA
Other - Middle Name:DAWN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1422 N KEALING AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-1506
Mailing Address - Country:US
Mailing Address - Phone:317-917-9172
Mailing Address - Fax:
Practice Address - Street 1:1422 N KEALING AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-1506
Practice Address - Country:US
Practice Address - Phone:317-917-9172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor