Provider Demographics
NPI:1831574334
Name:AGULLA, JENNAFER
Entity type:Individual
Prefix:
First Name:JENNAFER
Middle Name:
Last Name:AGULLA
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 1:203 ECKER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-6505
Mailing Address - Country:US
Mailing Address - Phone:631-338-0991
Mailing Address - Fax:
Practice Address - Street 1:203 ECKER AVE
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-6505
Practice Address - Country:US
Practice Address - Phone:631-338-0991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-25
Last Update Date:2015-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY632491121390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program