Provider Demographics
NPI:1558847616
Name:COLEMAN, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:COLEMAN
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 1:2317 KIBBY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3835
Mailing Address - Country:US
Mailing Address - Phone:517-489-8738
Mailing Address - Fax:
Practice Address - Street 1:2317 KIBBY RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-3835
Practice Address - Country:US
Practice Address - Phone:517-489-8738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No174200000XOther Service ProvidersMealsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI000000Medicaid