Provider Demographics
NPI:1194291583
Name:TRIPP, ANGELA C (PTA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:C
Last Name:TRIPP
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 WALWORTH ST
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-4230
Mailing Address - Country:US
Mailing Address - Phone:906-231-7264
Mailing Address - Fax:
Practice Address - Street 1:808 WALWORTH ST
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-4230
Practice Address - Country:US
Practice Address - Phone:906-231-7264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005064225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant