Provider Demographics
NPI:1043804990
Name:MBONY, IMMACULATE NGWE (APRN)
Entity Type:Individual
Prefix:
First Name:IMMACULATE
Middle Name:NGWE
Last Name:MBONY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 KINGS FIELD RD
Mailing Address - Street 2:
Mailing Address - City:DRACUT
Mailing Address - State:MA
Mailing Address - Zip Code:01826-1269
Mailing Address - Country:US
Mailing Address - Phone:978-726-2878
Mailing Address - Fax:
Practice Address - Street 1:100 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1708
Practice Address - Country:US
Practice Address - Phone:978-455-0756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2289761363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health