Healthcare Provider Details

I. General information

NPI: 1023835329
Provider Name (Legal Business Name): AGATHA ISI OGBEBOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 09/26/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 MARTIN LUTHER KING JR AVE SE
WASHINGTON DC
20032
US

IV. Provider business mailing address

3019 MARTIN LUTHER KING JR AVE SE
WASHINGTON DC
20032
US

V. Phone/Fax

Practice location:
  • Phone: 202-800-4433
  • Fax:
Mailing address:
  • Phone: 202-800-4433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: