Provider Demographics
NPI:1962683045
Name:AGNES O
Entity Type:Organization
Organization Name:AGNES O
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:SERWAH
Authorized Official - Last Name:OBENG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-207-1501
Mailing Address - Street 1:3630 BECKER ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADYNY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-2424
Mailing Address - Country:US
Mailing Address - Phone:518-207-1507
Mailing Address - Fax:
Practice Address - Street 1:3630 BECKER ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12304-2424
Practice Address - Country:US
Practice Address - Phone:518-207-1507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-17
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268485-13140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric