MEDICARE: LICEMEE MBAMA-MPOLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	355355	NY
2	163WM0102X	Maternal Newborn Registered Nurse	797276	NY

General Provider Information

NPI Number	:	1285401687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LICEMEE MBAMA-MPOLO

Provider Business Mailing Address
First Line	:	100 KINGS HWY S
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14617-5504
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1415 PORTLAND AVE STE 245
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14621-3022
Country	:	US
Telephone Number	:	585-922-4496
Fax Number	:	585-922-4442

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2023
Last Update Date	:	03/23/2026

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