Provider Demographics
NPI:1720350085
Name:WOSSUM, ANGEL LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:LYNN
Last Name:WOSSUM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10624 SUNNYS HALO CT
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:KY
Mailing Address - Zip Code:41091-7141
Mailing Address - Country:US
Mailing Address - Phone:859-630-6537
Mailing Address - Fax:
Practice Address - Street 1:7100 DIXIE HWY STE C
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-2098
Practice Address - Country:US
Practice Address - Phone:859-283-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0030225700000X
KY107549225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist