Provider Demographics
NPI:1780215285
Name:KIOKO, AGNETA WAVINYA IV
Entity Type:Individual
Prefix:
First Name:AGNETA
Middle Name:WAVINYA
Last Name:KIOKO
Suffix:IV
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 1:4224 GLENN ABBEY CROWLEY
Mailing Address - Street 2:4224 GLENN ABBEY CROWLEY
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036
Mailing Address - Country:US
Mailing Address - Phone:214-729-9323
Mailing Address - Fax:
Practice Address - Street 1:4224 GLEN ABBEY DR
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-8528
Practice Address - Country:US
Practice Address - Phone:214-729-9323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX351812164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse