Provider Demographics
NPI:1891912317
Name:PETERS, AGATHA
Entity Type:Individual
Prefix:MISS
First Name:AGATHA
Middle Name:
Last Name:PETERS
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 1:5331 BOEHM DR APT A
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-7706
Mailing Address - Country:US
Mailing Address - Phone:513-829-7297
Mailing Address - Fax:
Practice Address - Street 1:5331 BOEHM DR APT A
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-7706
Practice Address - Country:US
Practice Address - Phone:513-829-7297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2366247Medicaid