Provider Demographics
NPI:1922235183
Name:KILLPACK, ANGELA JEAN (OTR/L)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:JEAN
Last Name:KILLPACK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 SW 87TH AVE APT 703
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-6626
Mailing Address - Country:US
Mailing Address - Phone:801-671-3161
Mailing Address - Fax:
Practice Address - Street 1:10250 NW 53RD ST
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-8023
Practice Address - Country:US
Practice Address - Phone:954-746-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12928225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist