Provider Demographics
NPI:1366522633
Name:SUP, ANGELICA ROSE (OD)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:ROSE
Last Name:SUP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21911 76TH AVE W
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7903
Mailing Address - Country:US
Mailing Address - Phone:425-774-7723
Mailing Address - Fax:425-778-2788
Practice Address - Street 1:21911 76TH AVE W
Practice Address - Street 2:SUITE 101
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7903
Practice Address - Country:US
Practice Address - Phone:425-774-7723
Practice Address - Fax:425-778-2788
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003975152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0202735OtherL&I PROVIDER NUMBER
WA2161SUOtherREGENCE PROVIDER NUMBER
WA8856680Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
WA2161SUOtherREGENCE PROVIDER NUMBER