Provider Demographics
NPI:1457691065
Name:ANGELL, GEOFFREY GRAEME (PT)
Entity Type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:GRAEME
Last Name:ANGELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4164 LONICERA LOOP
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4531
Mailing Address - Country:US
Mailing Address - Phone:904-891-1179
Mailing Address - Fax:
Practice Address - Street 1:4164 LONICERA LOOP
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-4531
Practice Address - Country:US
Practice Address - Phone:904-891-1179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2014-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 21700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010501100Medicaid
HH060ZMedicare PIN