Provider Demographics
NPI:1962840777
Name:BRONESTINE, ANGELA M (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:BRONESTINE
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:720 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-1639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55774 MO-6
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MO
Practice Address - Zip Code:63537
Practice Address - Country:US
Practice Address - Phone:660-397-2282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056009307225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist