Provider Demographics
NPI:1487942553
Name:CHAVEZ, ANGELINA ROSE
Entity type:Individual
Prefix:
First Name:ANGELINA
Middle Name:ROSE
Last Name:CHAVEZ
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 1:1020 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-2313
Mailing Address - Country:US
Mailing Address - Phone:608-434-8377
Mailing Address - Fax:
Practice Address - Street 1:1020 5TH ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2313
Practice Address - Country:US
Practice Address - Phone:608-434-8377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI313581-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse