Provider Demographics
NPI:1962005447
Name:AGNISSEY, AMEYO FLORABELLE
Entity Type:Individual
Prefix:
First Name:AMEYO
Middle Name:FLORABELLE
Last Name:AGNISSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMEYO
Other - Middle Name:ESSI FLORABELE
Other - Last Name:YOPLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:95-246 AUHAELE LOOP
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-1205
Mailing Address - Country:US
Mailing Address - Phone:808-352-1039
Mailing Address - Fax:
Practice Address - Street 1:211 CARPENTER ST
Practice Address - Street 2:
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786
Practice Address - Country:US
Practice Address - Phone:808-305-1800
Practice Address - Fax:808-624-9505
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-19-89129106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician