Provider Demographics
NPI:1609317981
Name:AGOLLI, LUSILDA
Entity Type:Individual
Prefix:
First Name:LUSILDA
Middle Name:
Last Name:AGOLLI
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 1:4986 N ADAMS RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-5017
Mailing Address - Country:US
Mailing Address - Phone:248-475-4720
Mailing Address - Fax:
Practice Address - Street 1:4986 N ADAMS RD
Practice Address - Street 2:SUITE D
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48306-5017
Practice Address - Country:US
Practice Address - Phone:248-475-4720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
172V00000XOtherCHW