Provider Demographics
NPI:1861975534
Name:EMMACULATE, AGWESIP
Entity type:Individual
Prefix:
First Name:AGWESIP
Middle Name:
Last Name:EMMACULATE
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 1:6202 BALCONY LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75241-5059
Mailing Address - Country:US
Mailing Address - Phone:972-404-6542
Mailing Address - Fax:
Practice Address - Street 1:6202 BALCONY LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75241-5059
Practice Address - Country:US
Practice Address - Phone:972-404-6542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP62434164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse