Provider Demographics
NPI:1730948084
Name:SLOBODNIK, ANGELA LYNN (RD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:LYNN
Last Name:SLOBODNIK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7981 GLADIOLUS DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4154
Mailing Address - Country:US
Mailing Address - Phone:239-939-0999
Mailing Address - Fax:239-939-1070
Practice Address - Street 1:7981 GLADIOLUS DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4154
Practice Address - Country:US
Practice Address - Phone:239-939-0999
Practice Address - Fax:239-939-1070
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND10347133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered