Provider Demographics
NPI:1578037636
Name:DIPASQUALE, ANGELA NICOLE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:NICOLE
Last Name:DIPASQUALE
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 1:815 SEAGULL LN # DS101
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-6075
Mailing Address - Country:US
Mailing Address - Phone:949-887-0079
Mailing Address - Fax:
Practice Address - Street 1:815 SEAGULL LN # DS101
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-6075
Practice Address - Country:US
Practice Address - Phone:949-887-0079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95864612GMedicaid