Healthcare Provider Details

I. General information

NPI: 1639793722
Provider Name (Legal Business Name): PRISCO A NKEMBENG MBBS, MPH, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 09/29/2026
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 ANGEL AVE
HAVERHILL MA
01832-2567
US

IV. Provider business mailing address

5 ANGEL AVE
HAVERHILL MA
01832-2567
US

V. Phone/Fax

Practice location:
  • Phone: 781-475-6365
  • Fax:
Mailing address:
  • Phone: 781-475-6365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN2306433
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: