Provider Demographics
NPI:1477893980
Name:AGYEMAN, EDMOND (LPN)
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:
Last Name:AGYEMAN
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 FAIRFIELD CIR
Mailing Address - Street 2:12B
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4714
Mailing Address - Country:US
Mailing Address - Phone:631-835-6864
Mailing Address - Fax:
Practice Address - Street 1:4 FAIRFIELD CIR
Practice Address - Street 2:12B
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4714
Practice Address - Country:US
Practice Address - Phone:631-835-6864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-20
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311722-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse