Provider Demographics
NPI:1841306131
Name:KRUSE, ANGELA KAY (RD)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:KAY
Last Name:KRUSE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ZORN RD
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:IL
Mailing Address - Zip Code:62275-3644
Mailing Address - Country:US
Mailing Address - Phone:618-669-2395
Mailing Address - Fax:
Practice Address - Street 1:9495 HOLY CROSS LN
Practice Address - Street 2:SUITE 103
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230-3510
Practice Address - Country:US
Practice Address - Phone:618-526-2222
Practice Address - Fax:618-526-7680
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL204558Medicare ID - Type Unspecified
ILP52699Medicare UPIN