Provider Demographics
NPI:1225007040
Name:MOUSSA, ANGELA ROSE (RD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:ROSE
Last Name:MOUSSA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 S SHACKLEFORD RD
Mailing Address - Street 2:SUITE 439
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3527
Mailing Address - Country:US
Mailing Address - Phone:501-224-1690
Mailing Address - Fax:501-224-1927
Practice Address - Street 1:1 SAINT VINCENT CIR
Practice Address - Street 2:SUITE 210
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5405
Practice Address - Country:US
Practice Address - Phone:501-552-4777
Practice Address - Fax:501-552-4570
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR662133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y023Medicare ID - Type Unspecified