Healthcare Provider Details

I. General information

NPI: 1285401687
Provider Name (Legal Business Name): LICEMEE MBAMA-MPOLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2023
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 PORTLAND AVE STE 245
ROCHESTER NY
14621-3022
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-4496
  • Fax: 585-922-4442
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number355355
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number797276
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: