Provider Demographics
NPI:1740583426
Name:FREEMAN, AGNES MAE
Entity Type:Individual
Prefix:MRS
First Name:AGNES
Middle Name:MAE
Last Name:FREEMAN
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 1:160 HIBISCUS LN
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-9335
Mailing Address - Country:US
Mailing Address - Phone:407-792-9678
Mailing Address - Fax:
Practice Address - Street 1:160 HIBISCUS LN
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32738-9335
Practice Address - Country:US
Practice Address - Phone:407-792-9678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17200000X172V00000X
FL687652896172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687652897Medicaid
FL687652896Medicaid