Provider Demographics
NPI:1710218433
Name:AGNES, SANDRA A (CNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:A
Last Name:AGNES
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MEDICAL PARK DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622
Mailing Address - Country:US
Mailing Address - Phone:330-343-7709
Mailing Address - Fax:330-364-1538
Practice Address - Street 1:400 MEDICAL PARK DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622
Practice Address - Country:US
Practice Address - Phone:330-343-7709
Practice Address - Fax:330-364-1538
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA11157NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily