Provider Demographics
NPI:1710180260
Name:AMAJOYI AGUNENYE, CECILIA O (PA)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:O
Last Name:AMAJOYI AGUNENYE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 CRESTHAVEN RD 300
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0809
Mailing Address - Country:US
Mailing Address - Phone:901-683-0024
Mailing Address - Fax:
Practice Address - Street 1:255 E BONITA AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1923
Practice Address - Country:US
Practice Address - Phone:909-643-2980
Practice Address - Fax:909-596-3443
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA895363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA55699OtherSTATE LICENSE
TNPA895OtherSTATE LICENSE