Provider Demographics
NPI:1811069123
Name:PONCELAS, ANGELA MCNEILLY (MPT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MCNEILLY
Last Name:PONCELAS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 BROADWAY ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2226
Mailing Address - Country:US
Mailing Address - Phone:707-645-2563
Mailing Address - Fax:
Practice Address - Street 1:1761 BROADWAY ST
Practice Address - Street 2:SUITE 210
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2226
Practice Address - Country:US
Practice Address - Phone:707-645-2563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27223225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist