Provider Demographics
NPI:1982032389
Name:AGAYEVA, RENA
Entity Type:Individual
Prefix:
First Name:RENA
Middle Name:
Last Name:AGAYEVA
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:PO BOX 230346
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-0346
Mailing Address - Country:US
Mailing Address - Phone:917-374-0853
Mailing Address - Fax:
Practice Address - Street 1:1651 CONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-5849
Practice Address - Country:US
Practice Address - Phone:718-998-1415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY709046172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker