Provider Demographics
NPI:1003155144
Name:NDEGE, MARK NGAMBWA
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:NGAMBWA
Last Name:NDEGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5830 NW ZENITH DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3638
Mailing Address - Country:US
Mailing Address - Phone:772-342-4002
Mailing Address - Fax:
Practice Address - Street 1:5830 NW ZENITH DR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-3638
Practice Address - Country:US
Practice Address - Phone:772-342-4002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-09
Last Update Date:2013-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT5339225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist