Provider Demographics
NPI:1649864786
Name:DE ACOSTA, ANGELICA MARIA (CHW)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MARIA
Last Name:DE ACOSTA
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MOULTON AND PARSONS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:MN
Mailing Address - Zip Code:56081-5550
Mailing Address - Country:US
Mailing Address - Phone:507-375-8616
Mailing Address - Fax:
Practice Address - Street 1:1101 MOULTON AND PARSONS DR
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:MN
Practice Address - Zip Code:56081-5550
Practice Address - Country:US
Practice Address - Phone:507-375-8616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker