Provider Demographics
NPI:1417439118
Name:AGWENJANG, LESLY TEKE
Entity Type:Individual
Prefix:
First Name:LESLY
Middle Name:TEKE
Last Name:AGWENJANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 QUINCY ST APT B2
Mailing Address - Street 2:
Mailing Address - City:BLADENSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20710-2331
Mailing Address - Country:US
Mailing Address - Phone:202-705-4827
Mailing Address - Fax:
Practice Address - Street 1:5201 QUINCY STREET
Practice Address - Street 2:APT B2
Practice Address - City:BLANDESBURG
Practice Address - State:MD
Practice Address - Zip Code:20784
Practice Address - Country:US
Practice Address - Phone:202-705-4827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13933374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide