Provider Demographics
NPI:1154998045
Name:DE VERA, ANGELICA VILLACORTA
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:VILLACORTA
Last Name:DE VERA
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 1:20 TONNELE AVE APT 4C
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-5520
Mailing Address - Country:US
Mailing Address - Phone:551-208-7070
Mailing Address - Fax:
Practice Address - Street 1:20 TONNELE AVE APT 4C
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-5520
Practice Address - Country:US
Practice Address - Phone:551-208-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009160225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant