Provider Demographics
NPI:1124749015
Name:AGYEN, KWAME
Entity type:Individual
Prefix:
First Name:KWAME
Middle Name:
Last Name:AGYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 CIRCUIT AVE W
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01603-2156
Mailing Address - Country:US
Mailing Address - Phone:508-868-1576
Mailing Address - Fax:
Practice Address - Street 1:83 CIRCUIT AVE W
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-2156
Practice Address - Country:US
Practice Address - Phone:508-868-1576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2352031163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse