Provider Demographics
NPI:1861572505
Name:KASBOHM, ANGELA (LD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:KASBOHM
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:HOFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LD
Mailing Address - Street 1:2115 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-2109
Mailing Address - Country:US
Mailing Address - Phone:405-262-2640
Mailing Address - Fax:405-422-2521
Practice Address - Street 1:2115 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-2109
Practice Address - Country:US
Practice Address - Phone:405-262-2640
Practice Address - Fax:405-422-2521
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1068133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1068OtherLD LICENSE
OK244404301Medicare PIN