Provider Demographics
NPI:1962217067
Name:DEFORREST, ANGEL LYNN
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:LYNN
Last Name:DEFORREST
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 1:140 E TOWN ST STE 1450
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-6601
Mailing Address - Country:US
Mailing Address - Phone:614-639-6590
Mailing Address - Fax:
Practice Address - Street 1:4000 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:OH
Practice Address - Zip Code:43213-3593
Practice Address - Country:US
Practice Address - Phone:614-334-6903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005933175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist