Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TH0100X | Health Service | OH1200386 | OH |
NPI | 1174999130 |
---|---|
Provider Name | Angela Burris |
First Address | Fairfield, OH 45014-5946 |
Second Address | Liberty Township, OH 45044-9014 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2015 |
Last Update Date | 13/08/2015 |