Provider Demographics
NPI:1083638993
Name:AGBASSI, LAWANDA HICKS (NP)
Entity Type:Individual
Prefix:
First Name:LAWANDA
Middle Name:HICKS
Last Name:AGBASSI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8586 BUCKLAND DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-9616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15357 FARMINGTON RD
Practice Address - Street 2:SUITE 2
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-2863
Practice Address - Country:US
Practice Address - Phone:313-282-4527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704163985363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily