Healthcare Provider Details

I. General information

NPI: 1699721571
Provider Name (Legal Business Name): ELIZABETH NAMALA BWOGI CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 MAIN ST
BROCKTON MA
02301-4012
US

IV. Provider business mailing address

231 MAIN ST SUITE 302
BROCKTON MA
02301-4342
US

V. Phone/Fax

Practice location:
  • Phone: 508-559-6699
  • Fax: 508-583-4649
Mailing address:
  • Phone: 508-559-1567
  • Fax: 508-559-5073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number230164
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: