Provider Demographics
NPI:1750856571
Name:ANDERSON, ANGELA LORRAINE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LORRAINE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:ROSALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 S GILBERT RD APT 3098
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-0454
Mailing Address - Country:US
Mailing Address - Phone:480-433-2721
Mailing Address - Fax:
Practice Address - Street 1:5025 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-7437
Practice Address - Country:US
Practice Address - Phone:602-773-5773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA11511261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech