Provider Demographics
NPI:1013318864
Name:AGBOOLA, TANNEH PAULENNA (APN)
Entity Type:Individual
Prefix:
First Name:TANNEH
Middle Name:PAULENNA
Last Name:AGBOOLA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08629-2220
Mailing Address - Country:US
Mailing Address - Phone:609-599-5433
Mailing Address - Fax:609-475-4662
Practice Address - Street 1:1435 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08629-2220
Practice Address - Country:US
Practice Address - Phone:609-599-5433
Practice Address - Fax:609-475-4662
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00500900363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology