Provider Demographics
NPI:1942507660
Name:ANGEL, GENITA
Entity Type:Individual
Prefix:
First Name:GENITA
Middle Name:
Last Name:ANGEL
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 1:2448 N MERRIT CREEK LOOP
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4953
Mailing Address - Country:US
Mailing Address - Phone:208-664-2901
Mailing Address - Fax:208-667-9266
Practice Address - Street 1:2448 N MERRIT CREEK LOOP
Practice Address - Street 2:SUITE 2A
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4953
Practice Address - Country:US
Practice Address - Phone:208-664-2901
Practice Address - Fax:208-667-9266
Is Sole Proprietor?:No
Enumeration Date:2011-02-15
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-258225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
185598800OtherFEDERAL L&I
IDM0026441 171096043Medicaid
5003984OtherREGENCE MED ADVANTAGE
QMXPR0060660OtherMOLINA
TID 91051 NPIOtherGROUP HEALTH
82 0534955OtherID STATE INSURANCE FUND
82 0534955OtherIPN
82 0534955OtherSTERLING MEDADV
IDT9784OtherBLUE CROSS OF IDAHO
100000120993OtherREGENCE
TID NPI SSNOtherFIRST CHOICE
000010026877OtherREGENCE
0063788OtherWA L&I
82 053495583814A001OtherTRIWEST/TRICARE
DA3588OtherRAILROAD MEDICARE
82 0534955OtherID STATE INSURANCE FUND
ID4746230001Medicare NSC