Provider Demographics
NPI:1578970323
Name:AGBONA, CAROLINE
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:AGBONA
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 1:1138 RUNAWAY BAY DR
Mailing Address - Street 2:APT 3D
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-8732
Mailing Address - Country:US
Mailing Address - Phone:517-721-1709
Mailing Address - Fax:
Practice Address - Street 1:1138 RUNAWAY BAY DR
Practice Address - Street 2:APT 3D
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-8732
Practice Address - Country:US
Practice Address - Phone:517-721-1709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703107234164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse