=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942186507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGAPE FAMILY MEDICAL CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2025
-----------------------------------------------------
Last Update Date | 08/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1078 W MAIN ST STE 3
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06708-2651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-527-3576
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1078 W MAIN ST STE 3
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06708-2651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-527-3576
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FELISTAS MAZHANDU
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 203-527-3576
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------