Provider Demographics
NPI:1235953811
Name:PETERSON, ANGELA NICOLE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:NICOLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 KENWOOD DR APT J
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-2053
Mailing Address - Country:US
Mailing Address - Phone:216-450-0629
Mailing Address - Fax:
Practice Address - Street 1:421 KENWOOD DR APT J
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44123-2053
Practice Address - Country:US
Practice Address - Phone:216-450-0629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSZ831260172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver