Provider Demographics
NPI:1699330191
Name:MACE, ANGELA DAWN
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:DAWN
Last Name:MACE
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:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-0115
Mailing Address - Country:US
Mailing Address - Phone:712-246-0159
Mailing Address - Fax:712-246-2879
Practice Address - Street 1:523 W SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-1705
Practice Address - Country:US
Practice Address - Phone:712-246-0159
Practice Address - Fax:712-246-2879
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA092883101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health