Provider Demographics
NPI:1265137038
Name:PROPHET, ANGELA RENEE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:RENEE
Last Name:PROPHET
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 1:9271 E GRAND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:MI
Mailing Address - Zip Code:49777-8628
Mailing Address - Country:US
Mailing Address - Phone:740-297-0488
Mailing Address - Fax:
Practice Address - Street 1:9271 E GRAND LAKE RD
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:MI
Practice Address - Zip Code:49777-8628
Practice Address - Country:US
Practice Address - Phone:740-297-0488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH832735133V00000X
AL5186133V00000X
AR2356133V00000X
KS2457133V00000X
KY283032133V00000X
MD5931133V00000X
MO2019016829133V00000X
NV40478133V00000X
UT13187224-4901133V00000X
NH1401133V00000X
RI01253133V00000X
OH4023133V00000X
FL11796133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered