Provider Demographics
NPI:1205642295
Name:BROCKMEYER, ANGELA JOY (LPN)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:JOY
Last Name:BROCKMEYER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 S 3RD ST APT 204
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4775
Mailing Address - Country:US
Mailing Address - Phone:218-230-4190
Mailing Address - Fax:
Practice Address - Street 1:2201 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2101
Practice Address - Country:US
Practice Address - Phone:701-232-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDL10813164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse