Provider Demographics
NPI:1477996791
Name:TELLEN, AGNES
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:TELLEN
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 1:2642 12TH ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-1737
Mailing Address - Country:US
Mailing Address - Phone:202-269-1619
Mailing Address - Fax:202-683-6739
Practice Address - Street 1:2642 12TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-1737
Practice Address - Country:US
Practice Address - Phone:202-269-1619
Practice Address - Fax:202-683-6739
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1154581858Medicaid