Provider Demographics
NPI:1215907332
Name:WALLENBROCK, ANGELA B (MD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:B
Last Name:WALLENBROCK
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1570 HEATHERWAE LOOP
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-9363
Mailing Address - Country:US
Mailing Address - Phone:614-432-6410
Mailing Address - Fax:614-430-5744
Practice Address - Street 1:1570 HEATHERWAE LOOP
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-9363
Practice Address - Country:US
Practice Address - Phone:614-432-6410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35049858W2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0599320Medicaid
A16275Medicare UPIN