Provider Demographics
NPI:1427654680
Name:MENDOZA AGOUR, FATIMA JUMAWAN (LPN)
Entity type:Individual
Prefix:
First Name:FATIMA
Middle Name:JUMAWAN
Last Name:MENDOZA AGOUR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:FATIMA
Other - Middle Name:J
Other - Last Name:MENDOZA AGOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8401 MAIN ST APT 230
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-1713
Mailing Address - Country:US
Mailing Address - Phone:347-836-3960
Mailing Address - Fax:
Practice Address - Street 1:8401 MAIN ST APT 230
Practice Address - Street 2:
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435-1713
Practice Address - Country:US
Practice Address - Phone:347-836-3960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266614-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse