Healthcare Provider Details

I. General information

NPI: 1720845399
Provider Name (Legal Business Name): LEBGA N/A GWANVALLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 GARLAND ST
EVERETT MA
02149-5066
US

IV. Provider business mailing address

24 LUDLOW ST APT 3
WORCESTER MA
01603-1184
US

V. Phone/Fax

Practice location:
  • Phone: 617-389-6270
  • Fax:
Mailing address:
  • Phone: 781-975-1689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2347291
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: