Provider Demographics
NPI:1487143129
Name:ANDERSON, ANGELINA LUCRETIA (CPCP)
Entity type:Individual
Prefix:MRS
First Name:ANGELINA
Middle Name:LUCRETIA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CPCP
Other - Prefix:
Other - First Name:ANGELINA
Other - Middle Name:LUCRETIA
Other - Last Name:AIELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:191 NE GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2936
Mailing Address - Country:US
Mailing Address - Phone:971-337-5401
Mailing Address - Fax:
Practice Address - Street 1:191 NE GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2936
Practice Address - Country:US
Practice Address - Phone:971-337-5401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORBAP-TA-10190322246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other