Provider Demographics
NPI:1164043683
Name:BANGU, NINA PHILICIA (RN, BSN)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:PHILICIA
Last Name:BANGU
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18837 SMITH DR NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-7510
Mailing Address - Country:US
Mailing Address - Phone:763-291-1069
Mailing Address - Fax:
Practice Address - Street 1:18837 SMITH DR NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-7510
Practice Address - Country:US
Practice Address - Phone:763-291-1069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1103992251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0001057364OtherWAIVERS