Provider Demographics
NPI:1013510668
Name:JANIS, ANGELA MARIE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:JANIS
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 1:7657 E TANK POND RD
Mailing Address - Street 2:
Mailing Address - City:NABB
Mailing Address - State:IN
Mailing Address - Zip Code:47147-7067
Mailing Address - Country:US
Mailing Address - Phone:181-257-2303
Mailing Address - Fax:
Practice Address - Street 1:1350 N TODD DR
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-7755
Practice Address - Country:US
Practice Address - Phone:812-752-5663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002800A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant