Provider Demographics
NPI:1598280737
Name:AGIVAIVE, IRENE (RN)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:AGIVAIVE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 SHOTWELL AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312
Mailing Address - Country:US
Mailing Address - Phone:929-335-3712
Mailing Address - Fax:888-679-5645
Practice Address - Street 1:262 SHOTWELL AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1963
Practice Address - Country:US
Practice Address - Phone:929-335-3712
Practice Address - Fax:888-679-5645
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04606268Medicaid