Provider Demographics
NPI:1205670874
Name:STILLIONS, ANGELINA RAE (LMT)
Entity type:Individual
Prefix:
First Name:ANGELINA
Middle Name:RAE
Last Name:STILLIONS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7758 STATE ROUTE 89
Mailing Address - Street 2:
Mailing Address - City:INTERLAKEN
Mailing Address - State:NY
Mailing Address - Zip Code:14847-9642
Mailing Address - Country:US
Mailing Address - Phone:607-339-6506
Mailing Address - Fax:
Practice Address - Street 1:1212 TRUMANSBURG RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1314
Practice Address - Country:US
Practice Address - Phone:607-288-2205
Practice Address - Fax:607-793-9464
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033517-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist