Provider Demographics
NPI:1942437744
Name:FERN, ANGELA (CMT, LMT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:FERN
Suffix:
Gender:F
Credentials:CMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 MAPLEWOOD DR STE 215
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1980
Mailing Address - Country:US
Mailing Address - Phone:651-338-4357
Mailing Address - Fax:
Practice Address - Street 1:2485 MAPLEWOOD DR STE 215
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1980
Practice Address - Country:US
Practice Address - Phone:651-338-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNBL-000528225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist