Provider Demographics
NPI:1255099610
Name:AGIBALOVA, INGA
Entity type:Individual
Prefix:
First Name:INGA
Middle Name:
Last Name:AGIBALOVA
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 1:535 DUNSTEN CIR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2610
Mailing Address - Country:US
Mailing Address - Phone:847-710-1570
Mailing Address - Fax:
Practice Address - Street 1:535 DUNSTEN CIR
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2610
Practice Address - Country:US
Practice Address - Phone:847-710-1570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer