Provider Demographics
NPI:1407324064
Name:AGAMI, ANGELICA LEE (MS, BA, RD)
Entity Type:Individual
Prefix:MRS
First Name:ANGELICA
Middle Name:LEE
Last Name:AGAMI
Suffix:
Gender:F
Credentials:MS, BA, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 ERSKINE DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-2548
Mailing Address - Country:US
Mailing Address - Phone:917-680-9033
Mailing Address - Fax:
Practice Address - Street 1:16305 SAND CANYON AVE STE 210
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3783
Practice Address - Country:US
Practice Address - Phone:949-752-2227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1064149133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered