Provider Demographics
NPI:1376746719
Name:RYSTROM, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:RYSTROM
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 1:8480 SIGNAL HILL RD
Mailing Address - Street 2:APT 402
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-7034
Mailing Address - Country:US
Mailing Address - Phone:402-720-6639
Mailing Address - Fax:
Practice Address - Street 1:2101 AIRLINE RD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-2641
Practice Address - Country:US
Practice Address - Phone:361-993-4778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1239090225100000X
VA2305205039225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist