Provider Demographics
NPI:1992930135
Name:GRADY, ANGELA FENELL (DPM)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:FENELL
Last Name:GRADY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20800 WESTGATE MALL
Mailing Address - Street 2:SUITE 401
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-1323
Mailing Address - Country:US
Mailing Address - Phone:440-333-7722
Mailing Address - Fax:440-356-0310
Practice Address - Street 1:20800 WESTGATE MALL
Practice Address - Street 2:SUITE 401
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-1323
Practice Address - Country:US
Practice Address - Phone:440-333-7722
Practice Address - Fax:440-356-0310
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003596213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0061544Medicaid
OH0061544Medicaid