Provider Demographics
NPI:1750641288
Name:FORD-BURGESS, AGNES (RN)
Entity Type:Individual
Prefix:MRS
First Name:AGNES
Middle Name:
Last Name:FORD-BURGESS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 S OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-5538
Mailing Address - Country:US
Mailing Address - Phone:516-867-5381
Mailing Address - Fax:516-379-6887
Practice Address - Street 1:450 S OCEAN AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-5538
Practice Address - Country:US
Practice Address - Phone:516-867-5381
Practice Address - Fax:516-379-6887
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY380999163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool