Provider Demographics
NPI:1922373505
Name:HAVILAND, ANGELA DEE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:DEE
Last Name:HAVILAND
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 1:900 W 1ST ST
Mailing Address - Street 2:200
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-5675
Mailing Address - Country:US
Mailing Address - Phone:775-677-2216
Mailing Address - Fax:
Practice Address - Street 1:900 W 1ST ST
Practice Address - Street 2:200
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-5675
Practice Address - Country:US
Practice Address - Phone:775-677-2216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV172V00000X172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV172VOOOOOXMedicaid