Provider Demographics
NPI:1174384739
Name:AGATEP, MARIA ELIDA B (LVN)
Entity type:Individual
Prefix:
First Name:MARIA ELIDA
Middle Name:B
Last Name:AGATEP
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7251 TIARA LN
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1159
Mailing Address - Country:US
Mailing Address - Phone:714-420-2218
Mailing Address - Fax:
Practice Address - Street 1:11818 SOUTH ST STE 207
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-6831
Practice Address - Country:US
Practice Address - Phone:714-420-2218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN217549164X00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No164X00000XNursing Service ProvidersLicensed Vocational Nurse