Provider Demographics
NPI:1811794597
Name:COLE, ANGELIQUE VICKIE
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:VICKIE
Last Name:COLE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:ANGELIQUE
Other - Middle Name:
Other - Last Name:CHACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16745 BIG BEAR RD
Mailing Address - Street 2:
Mailing Address - City:LOWER LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95457-9712
Mailing Address - Country:US
Mailing Address - Phone:707-206-5204
Mailing Address - Fax:
Practice Address - Street 1:3642 BLUE GUM ST
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-7939
Practice Address - Country:US
Practice Address - Phone:707-266-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-28
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171W00000XOther Service ProvidersContractorGroup - Single Specialty
No177F00000XOther Service ProvidersLodging