MEDICARE: DESOLA-VASILISA BAMGBALA RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0808X	Psychiatric/Mental Health Registered Nurse	RN2373211	MA

General Provider Information

NPI Number	:	1275334351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESOLA-VASILISA BAMGBALA RN

Provider Business Mailing Address
First Line	:	16 ISLAND HILL AVE UNIT 310
Second Line	:
City	:	MELROSE
State	:	MA
Zip	:	02176-6140
Country	:	US
Telephone Number	:	917-340-6534
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 ISLAND HILL AVE UNIT 310
Second Line	:
City	:	MELROSE
State	:	MA
Zip	:	02176-6140
Country	:	US
Telephone Number	:	917-340-6534
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2025
Last Update Date	:	03/24/2025

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