Provider Demographics
NPI:1396339560
Name:AGNI, LISA-MARIE LUMABAO
Entity type:Individual
Prefix:
First Name:LISA-MARIE
Middle Name:LUMABAO
Last Name:AGNI
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 1:8616 2ND AVE APT 103
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3787
Mailing Address - Country:US
Mailing Address - Phone:808-497-6506
Mailing Address - Fax:
Practice Address - Street 1:4001 N COOK ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-5879
Practice Address - Country:US
Practice Address - Phone:509-326-4382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program