Provider Demographics
NPI:1871622761
Name:IHENACHO, AGATHA N (LPT)
Entity type:Individual
Prefix:
First Name:AGATHA
Middle Name:N
Last Name:IHENACHO
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:AGATHA
Other - Middle Name:N
Other - Last Name:EZEKA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPT
Mailing Address - Street 1:6381 BLACKBERRY CT
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-3424
Mailing Address - Country:US
Mailing Address - Phone:408-848-9802
Mailing Address - Fax:
Practice Address - Street 1:455 SILICON VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95138
Practice Address - Country:US
Practice Address - Phone:408-284-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT31594167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician