Provider Demographics
NPI:1992197644
Name:AGYEMAN, SHANTEL
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:
Last Name:AGYEMAN
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 1:185 MCCLELLAN ST
Mailing Address - Street 2:APT 5S
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-4810
Mailing Address - Country:US
Mailing Address - Phone:347-662-8188
Mailing Address - Fax:
Practice Address - Street 1:185 MCCLELLAN ST
Practice Address - Street 2:APT 5S
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-4810
Practice Address - Country:US
Practice Address - Phone:347-662-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320423-1390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program