Healthcare Provider Details

I. General information

NPI: 1619623980
Provider Name (Legal Business Name): NORAH ALILA OTIENO-WASONGA RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NORAH ALILA WASONGA-GERMAIN

II. Dates (important events)

Enumeration Date: 02/25/2022
Last Update Date: 02/25/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 GORE ST
CAMBRIDGE MA
02141-1119
US

IV. Provider business mailing address

163 GORE ST
CAMBRIDGE MA
02141-1119
US

V. Phone/Fax

Practice location:
  • Phone: 781-605-4532
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number5534-NU-NU
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: