1457907958 NPI number — MRS. ANGELA MICHELLE STREET RDN, LD

Table of content: DR. THOMAS BUCKLEY MD (NPI 1750312443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457907958 NPI number — MRS. ANGELA MICHELLE STREET RDN, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STREET
Provider First Name:
ANGELA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RDN, LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457907958
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 E JACKSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31021-6113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-274-3012
Provider Business Mailing Address Fax Number:
478-274-7719

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 MERCER DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021-4257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-274-3012
Provider Business Practice Location Address Fax Number:
478-274-7719
Provider Enumeration Date:
08/12/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  876892 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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