Provider Demographics
NPI:1053900043
Name:BUBLIK, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BUBLIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5506 SE LEXINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-9024
Mailing Address - Country:US
Mailing Address - Phone:971-313-3778
Mailing Address - Fax:
Practice Address - Street 1:5506 SE LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-9024
Practice Address - Country:US
Practice Address - Phone:971-313-3778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU60903817133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist