Healthcare Provider Details

I. General information

NPI: 1962060871
Provider Name (Legal Business Name): ANTONINA Y AGAFONOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 ONTARIO RD NW
WASHINGTON DC
20009-2144
US

IV. Provider business mailing address

12213 VILLAGE SQUARE TER APT 102
ROCKVILLE MD
20852-1921
US

V. Phone/Fax

Practice location:
  • Phone: 202-320-0250
  • Fax:
Mailing address:
  • Phone: 240-533-7679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT1838
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: