Provider Demographics
NPI:1386926764
Name:CRANDALL, ANGELIQUE S (LD)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:S
Last Name:CRANDALL
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7510 MONTGOMERY BLVD NE STE 203
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1500
Mailing Address - Country:US
Mailing Address - Phone:505-855-5545
Mailing Address - Fax:
Practice Address - Street 1:7510 MONTGOMERY BLVD NE STE 203
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1500
Practice Address - Country:US
Practice Address - Phone:505-855-5545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-0825133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMLD-0825OtherSTATE OF NM BOARD OF NUTRITION PRACTITIONERS