Provider Demographics
NPI:1124593686
Name:VAILES, ANGELIQUE LYNETTE
Entity type:Individual
Prefix:MS
First Name:ANGELIQUE
Middle Name:LYNETTE
Last Name:VAILES
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 1:3510 65TH AVE UNIT 10F
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20784-2464
Mailing Address - Country:US
Mailing Address - Phone:240-375-1670
Mailing Address - Fax:
Practice Address - Street 1:3510 65TH AVE UNIT 10F
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20784-2464
Practice Address - Country:US
Practice Address - Phone:240-375-1670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD118206174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD47-459-3895OtherTIN