Provider Demographics
NPI:1972358000
Name:GRANGE, ANGELIQUA FONSECA (MD)
Entity Type:Individual
Prefix:
First Name:ANGELIQUA
Middle Name:FONSECA
Last Name:GRANGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 REINDEER CRES
Mailing Address - Street 2:
Mailing Address - City:VAUGHAN
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L4H 2E9
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050
Practice Address - Country:US
Practice Address - Phone:815-344-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program