Provider Demographics
NPI:1245715077
Name:SMITH, ANGELA
Entity type:Individual
Prefix:MISS
First Name:ANGELA
Middle Name:
Last Name:SMITH
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 1:33870 BLUE STAR HWY
Mailing Address - Street 2:APT1107
Mailing Address - City:MIDWAY
Mailing Address - State:FLORIDA
Mailing Address - Zip Code:32343
Mailing Address - Country:AO
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33870 BLUE STAR HWY APT 1107
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:FL
Practice Address - Zip Code:32343-2434
Practice Address - Country:US
Practice Address - Phone:850-264-1909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL235607247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
235607OtherHOMEMAKE AND COMPANION SERVICES