Provider Demographics
NPI:1932538709
Name:LIGHT, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:LIGHT
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 1:12920 SHAFER RD
Mailing Address - Street 2:
Mailing Address - City:LICKING
Mailing Address - State:MO
Mailing Address - Zip Code:65542-9413
Mailing Address - Country:US
Mailing Address - Phone:417-260-4160
Mailing Address - Fax:
Practice Address - Street 1:12920 SHAFER RD
Practice Address - Street 2:
Practice Address - City:LICKING
Practice Address - State:MO
Practice Address - Zip Code:65542-9413
Practice Address - Country:US
Practice Address - Phone:417-260-4160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO127669171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator