Provider Demographics
NPI:1083376438
Name:TAKEM TAKANG, AGNES
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:TAKEM TAKANG
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 1:6089 SANDGATE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-2716
Mailing Address - Country:US
Mailing Address - Phone:614-357-3799
Mailing Address - Fax:
Practice Address - Street 1:6089 SANDGATE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-2716
Practice Address - Country:US
Practice Address - Phone:614-357-3799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH163982164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH163982OtherLPN