Provider Demographics
NPI:1093030942
Name:JENGO, NELLY (LMT)
Entity Type:Individual
Prefix:MRS
First Name:NELLY
Middle Name:
Last Name:JENGO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18942 NW 46 AVENUE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33055-2659
Mailing Address - Country:US
Mailing Address - Phone:786-222-4640
Mailing Address - Fax:
Practice Address - Street 1:18942 NW 46TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-2659
Practice Address - Country:US
Practice Address - Phone:786-222-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 52209174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist