Healthcare Provider Details

I. General information

NPI: 1760823751
Provider Name (Legal Business Name): NGOZI QUEEN NKANGINIEME M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

1 EMERSON PL APT 17M
BOSTON MA
02114-2216
US

V. Phone/Fax

Practice location:
  • Phone: 857-574-9737
  • Fax:
Mailing address:
  • Phone: 330-285-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number127543
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number272674
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: