Basic Information
| Provider Information | |||||||||
| NPI: | 1396092144 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARRETT | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3225 BORDEAU DR | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637013403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732759879 | ||||||||
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| Practice Location | |||||||||
| Address1: | 806 S KINGSHIGHWAY ST | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638015919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734710110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2012 | ||||||||
| LastUpdateDate: | 08/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2012023604 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.