Provider Demographics
NPI:1982170825
Name:WALT, ANGELA (RD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WALT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:NANTAIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:130 TOWN CENTER DR STE 203
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:248-585-8265
Mailing Address - Fax:248-585-8266
Practice Address - Street 1:1555 SOUTH BLVD E STE 360
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5759
Practice Address - Country:US
Practice Address - Phone:248-267-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered