Provider Demographics
NPI:1174912661
Name:MAILLET, ANGEL
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:MAILLET
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 1:46715 WESTOVER TER
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-7506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46715 WESTOVER TER
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-7506
Practice Address - Country:US
Practice Address - Phone:703-297-5162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAS5386612246ZE0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG