Provider Demographics
NPI:1467849968
Name:MGLEJ KEMP, AGNIESZKA
Entity Type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:
Last Name:MGLEJ KEMP
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:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-0727
Mailing Address - Country:US
Mailing Address - Phone:541-247-7000
Mailing Address - Fax:541-247-9000
Practice Address - Street 1:29980 ELLENSBURG AVE
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-7808
Practice Address - Country:US
Practice Address - Phone:541-247-7000
Practice Address - Fax:541-247-9000
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC169995171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist