Basic Information
| Provider Information | |||||||||
| NPI: | 1912155052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOERST | ||||||||
| FirstName: | ANGELIQUE | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MA CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 SOUTH STATE STREET | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 EAST MEDICAL CENTER DRIVE | ||||||||
| Address2: | 2ND FLOOR TAUBMAN CENTER RECP A | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481094227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349365730 | ||||||||
| FaxNumber: | 7346150544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2008 | ||||||||
| LastUpdateDate: | 11/20/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 1601000054 | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | 1601000054 | MI | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.