Provider Demographics
NPI:1861662652
Name:WANLESS, ANGELA S
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:S
Last Name:WANLESS
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 1:343 KEPNER DR NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5144
Mailing Address - Country:US
Mailing Address - Phone:850-243-1140
Mailing Address - Fax:
Practice Address - Street 1:119 TRUXTON AVE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-2460
Practice Address - Country:US
Practice Address - Phone:850-305-6006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA31729225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist