Provider Demographics
NPI:1457050833
Name:GENTILE, ANGELICA BROOKE ELIZABETH
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:BROOKE ELIZABETH
Last Name:GENTILE
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 1:5 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-1057
Mailing Address - Country:US
Mailing Address - Phone:781-233-9787
Mailing Address - Fax:
Practice Address - Street 1:5 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-1057
Practice Address - Country:US
Practice Address - Phone:781-233-9787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5011635171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor