Provider Demographics
NPI:1043740459
Name:TITA, MANGA FOMBUH
Entity Type:Individual
Prefix:
First Name:MANGA
Middle Name:FOMBUH
Last Name:TITA
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 1:8194 COLYN CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45044-8752
Mailing Address - Country:US
Mailing Address - Phone:513-237-0119
Mailing Address - Fax:
Practice Address - Street 1:8194 COLYN CT
Practice Address - Street 2:
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45044-8752
Practice Address - Country:US
Practice Address - Phone:513-237-0119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH355688163W00000X, 163WG0600X, 163WH0200X, 163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163W00000XNursing Service ProvidersRegistered Nurse
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
No163WH0200XNursing Service ProvidersRegistered NurseHome Health