Provider Demographics
NPI:1265093850
Name:SHEYBANI-AGDAM, KRISTINA MARIE (LPN)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:MARIE
Last Name:SHEYBANI-AGDAM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:MARIE
Other - Last Name:LUNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:284 EXECUTIVE PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:524 SIGNAL HILL DRIVE EXT
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4391
Practice Address - Country:US
Practice Address - Phone:704-871-1045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC81952164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse