Provider Demographics
NPI:1366904377
Name:FAUST, ANGELA BOGLE (PTA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:BOGLE
Last Name:FAUST
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 VAN HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4342
Mailing Address - Country:US
Mailing Address - Phone:704-883-9700
Mailing Address - Fax:
Practice Address - Street 1:2001 VAN HAVEN DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4342
Practice Address - Country:US
Practice Address - Phone:704-883-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1145225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant