1033692009 NPI number — FELICIA ABENA AGYEMANG WIREDU LICENSE NURSE

Table of content: FELICIA ABENA AGYEMANG WIREDU LICENSE NURSE (NPI 1033692009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033692009 NPI number — FELICIA ABENA AGYEMANG WIREDU LICENSE NURSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AGYEMANG WIREDU
Provider First Name:
FELICIA
Provider Middle Name:
ABENA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICENSE NURSE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AGYEMANG
Provider Other First Name:
FELICIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LICENSE NURSE
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1033692009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 SHADY OAK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92882-5943
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-858-8164
Provider Business Mailing Address Fax Number:
951-278-1251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 SHADY OAK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92882-5943
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-858-8164
Provider Business Practice Location Address Fax Number:
951-278-1251
Provider Enumeration Date:
09/14/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164X00000X , with the licence number:  684625 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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