Provider Demographics
NPI:1568852150
Name:PERCOCO, AGNES
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:PERCOCO
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 1:627 JAYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2947
Mailing Address - Country:US
Mailing Address - Phone:631-331-5218
Mailing Address - Fax:
Practice Address - Street 1:627 JAYNE BLVD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11776-2947
Practice Address - Country:US
Practice Address - Phone:631-331-5218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144237-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse