Provider Demographics
NPI:1194276501
Name:ANGELLO, SHANTELLE (LMT)
Entity type:Individual
Prefix:MRS
First Name:SHANTELLE
Middle Name:
Last Name:ANGELLO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 PATTERSON RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-1941
Mailing Address - Country:US
Mailing Address - Phone:970-248-9833
Mailing Address - Fax:970-248-9835
Practice Address - Street 1:2646 PATTERSON RD
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-1941
Practice Address - Country:US
Practice Address - Phone:970-248-9833
Practice Address - Fax:970-248-9835
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0001984225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC808464Medicare UPIN