Agnes Liem, CPNP-PC, AE-C
Individual provider Active NPI Pediatric Nurse Practitioner · Minot Afb, ND
NPI 1508097247 · NPPES record last updated Apr 28, 2016
Key facts
- NPI
- 1508097247
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pediatric Nurse Practitioner 363LP0200X
- License
- F382111-1 (NY)
- Practice address
- 10 Missile Ave
Minot Afb, ND 58705-5003 - Phone
- (701) 723-5138
- Fax
- (609) 754-9195
- NPI assigned
- Jul 29, 2009
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 4
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ND
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160725001367 | ND | Practitioner - Nurse Practitioner | 6103877634 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 601494-1 | NY | MD | Registered Nurse |
| 026.0042618 | VT | MD | Registered Nurse |
| F382111-1 | NY | MD | Pediatric Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Innovis Health LLC | Current |
Accepting new patients | |
| Innovis Health, LLC | Current | Accepting new patients | |
| Innovis Health LLC | Current |
Accepting new patients | |
| Primary Care Health Partners - Vermont LLP | Past |
Accepting new patients |
Locations
3000 32nd Ave S
Fargo, ND 58103
Phone (701) 364-3000
1702 University Dr S
Fargo, ND 58103
Phone (701) 364-4222
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Nurse | 163W00000X | 601494-1 | NY | |
| Registered Nurse | 163W00000X | 026.0042618 | VT | |
| Pediatric Nurse Practitioner | 363LP0200X | F382111-1 | NY | Yes |
| Pediatric Nurse Practitioner | 363LP0200X | R43064 | ND |
Addresses
Primary practice location
10 Missile Ave
Minot Afb, ND 58705-5003
Mailing address
194 Missile Ave
Minot Afb, ND 58701
Phone (701) 723-5138
Other providers in Minot Afb, ND
- Lisa Krogman
- Zsuzsanna Danuta Krokovay
- Andrea Marie Larocque
- Soo Young Lee
- Julianne Legierse
- Robert B Long
- Shianne M Lundy
- Samuel Madden
- Kerri Beth Carson Mannion
- Tyler Marshall
All providers in Minot Afb, ND · Pediatric Nurse Practitioner in North Dakota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 28, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.