Provider Demographics
NPI:1780390542
Name:DAVIS, ANGELA INDIGO (MPH RD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:INDIGO
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MPH RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20032 STRATHMOOR ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1684
Mailing Address - Country:US
Mailing Address - Phone:313-614-4725
Mailing Address - Fax:
Practice Address - Street 1:20032 STRATHMOOR ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1684
Practice Address - Country:US
Practice Address - Phone:313-614-4725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI374J00000X
MI86168506133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No374J00000XNursing Service Related ProvidersDoula