Provider Demographics
NPI:1235529264
Name:AGNEW, RENITA
Entity Type:Individual
Prefix:MRS
First Name:RENITA
Middle Name:
Last Name:AGNEW
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 1:36869 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4474
Mailing Address - Country:US
Mailing Address - Phone:313-460-3753
Mailing Address - Fax:313-460-3753
Practice Address - Street 1:36869 CARRIAGE DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4474
Practice Address - Country:US
Practice Address - Phone:313-460-3753
Practice Address - Fax:313-460-3753
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor