MEDICARE: IMMACULATE ASABA KEMIGABO NURSE

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	163W00000X	Registered Nurse	594414-1	NY

General Provider Information

NPI Number	:	1861055261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IMMACULATE ASABA KEMIGABO NURSE

Provider Business Mailing Address
First Line	:	698 PONTIAC PL # 3
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-3115
Country	:	US
Telephone Number	:	917-588-9621
Fax Number	:

Provider Business Practice Location Address
First Line	:	698 PONTIAC PL # 3
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-3115
Country	:	US
Telephone Number	:	917-588-9621
Fax Number	:

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

Provider Enumeration Date	:	04/21/2019
Last Update Date	:	04/21/2019

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