Provider Demographics
NPI:1871837328
Name:DELEAWE, AGNES TITILAYO (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:TITILAYO
Last Name:DELEAWE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 W PIONEER PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-4703
Mailing Address - Country:US
Mailing Address - Phone:817-680-8148
Mailing Address - Fax:
Practice Address - Street 1:923 BENTWATER PKWY
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-8268
Practice Address - Country:US
Practice Address - Phone:817-521-3353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-22
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX736492164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse