Provider Demographics
NPI:1699793331
Name:HOMUTH, ANGELA BETH (CDE)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:BETH
Last Name:HOMUTH
Suffix:
Gender:F
Credentials:CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 ELM ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2417
Mailing Address - Country:US
Mailing Address - Phone:701-232-3241
Mailing Address - Fax:701-237-2573
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:701-232-3241
Practice Address - Fax:701-237-2573
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR25394163WD0400X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
N/AMedicare UPIN