Provider Demographics
NPI:1063644219
Name:IKE, KAMMA MUONYE (RN)
Entity Type:Individual
Prefix:MRS
First Name:KAMMA
Middle Name:MUONYE
Last Name:IKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:56 ORMOND ST
Mailing Address - Street 2:APT # 2
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-1508
Mailing Address - Country:US
Mailing Address - Phone:617-696-2746
Mailing Address - Fax:
Practice Address - Street 1:780 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2524
Practice Address - Country:US
Practice Address - Phone:857-654-1037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA257678163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1063644219Medicare PIN