Provider Demographics
NPI:1720818396
Name:AGWENJANG, NERIS
Entity type:Individual
Prefix:
First Name:NERIS
Middle Name:
Last Name:AGWENJANG
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 1:3315 CHAUNCEY PL APT 303
Mailing Address - Street 2:
Mailing Address - City:MOUNT RAINIER
Mailing Address - State:MD
Mailing Address - Zip Code:20712-1018
Mailing Address - Country:US
Mailing Address - Phone:240-676-8061
Mailing Address - Fax:
Practice Address - Street 1:702 15TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4508
Practice Address - Country:US
Practice Address - Phone:202-388-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker