Provider Demographics
NPI:1043345267
Name:DAVIS, ANGELA JEAN (LMT)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:JEAN
Last Name:DAVIS
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 1:9025 SW OAK ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6547
Mailing Address - Country:US
Mailing Address - Phone:503-481-4945
Mailing Address - Fax:
Practice Address - Street 1:18039 SW LOWER BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7228
Practice Address - Country:US
Practice Address - Phone:503-481-4945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11689225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist