Individual
ANGELICA ROSE SUP
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
O.D.
Contact information
Practice address
21911 76TH AVE W, SUITE 101, EDMONDS, WA 98026-7903
(425) 774-7723
(425) 778-2788
Mailing address
21911 76TH AVE W, SUITE 101, EDMONDS, WA 98026-7903
(425) 774-7723
(425) 778-2788
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
OD00003975
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0202735
L&I PROVIDER NUMBER
WA
01
—
2161SU
REGENCE PROVIDER NUMBER
WA
Enumeration date
10/17/2006
Last updated
07/09/2007
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