Provider Demographics
NPI:1215313952
Name:MOSLEY, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MOSLEY
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 1:1905 MONTIE RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-1282
Mailing Address - Country:US
Mailing Address - Phone:313-655-5017
Mailing Address - Fax:313-381-2031
Practice Address - Street 1:1905 MONTIE RD
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-1282
Practice Address - Country:US
Practice Address - Phone:313-655-5017
Practice Address - Fax:313-381-2031
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM242067594263172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker