Provider Demographics
NPI:1457907958
Name:STREET, ANGELA MICHELLE (RDN, LD)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MICHELLE
Last Name:STREET
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-6113
Mailing Address - Country:US
Mailing Address - Phone:478-274-3012
Mailing Address - Fax:478-274-7719
Practice Address - Street 1:103 MERCER DR STE B
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-4257
Practice Address - Country:US
Practice Address - Phone:478-274-3012
Practice Address - Fax:478-274-7719
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA876892133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty