Basic Information
| Provider Information | |||||||||
| NPI: | 1457907958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STREET | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RDN, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 E JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310216113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782743012 | ||||||||
| FaxNumber: | 4782747719 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 MERCER DR STE B | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310214257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782743012 | ||||||||
| FaxNumber: | 4782747719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2019 | ||||||||
| LastUpdateDate: | 08/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 876892 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.