Provider Demographics
NPI:1851041248
Name:LISKOVEC, ANGELA DAWN (RN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:DAWN
Last Name:LISKOVEC
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10010 S WESTNEDGE AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-6877
Mailing Address - Country:US
Mailing Address - Phone:269-370-8007
Mailing Address - Fax:
Practice Address - Street 1:10010 S WESTNEDGE AVE APT 2D
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-6877
Practice Address - Country:US
Practice Address - Phone:269-370-8007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704218303163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse