Provider Demographics
NPI:1063206399
Name:CHAVEZ, AGELICA
Entity type:Individual
Prefix:
First Name:AGELICA
Middle Name:
Last Name:CHAVEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SIOUX CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68776-1553
Mailing Address - Country:US
Mailing Address - Phone:712-204-2730
Mailing Address - Fax:
Practice Address - Street 1:609 8TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-1553
Practice Address - Country:US
Practice Address - Phone:712-204-2730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE372600000X, 3747P1801X, 372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant