Healthcare Provider Details

I. General information

NPI: 1922669399
Provider Name (Legal Business Name): NEMATOU W ZONGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MADISON AVE STE 1415
NEW YORK NY
10017-1111
US

IV. Provider business mailing address

121 N HIGH ST APT 3
MOUNT VERNON NY
10550-1879
US

V. Phone/Fax

Practice location:
  • Phone: 646-673-8415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number767716
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number767716
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: