Provider Demographics
NPI:1578041927
Name:MUTTAY, AGNES J
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:J
Last Name:MUTTAY
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 1:30 INGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-1402
Mailing Address - Country:US
Mailing Address - Phone:585-224-6919
Mailing Address - Fax:
Practice Address - Street 1:30 INGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-1402
Practice Address - Country:US
Practice Address - Phone:585-224-6919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-29
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY325872-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse