Provider Demographics
NPI:1093423477
Name:NYAMONGO, ANASTACIA
Entity Type:Individual
Prefix:
First Name:ANASTACIA
Middle Name:
Last Name:NYAMONGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 CATOR AVE # 2
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-2003
Mailing Address - Country:US
Mailing Address - Phone:201-705-2324
Mailing Address - Fax:
Practice Address - Street 1:416 CATOR AVE # 2
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07305-2003
Practice Address - Country:US
Practice Address - Phone:201-705-2324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY82439301163W00000X
NY824393163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse