Provider Demographics
NPI:1336694066
Name:MAVEGAM TANGO ASSOUMOU M, BERTILLE OCTAVIE
Entity Type:Individual
Prefix:
First Name:BERTILLE OCTAVIE
Middle Name:
Last Name:MAVEGAM TANGO ASSOUMOU M
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 1:22 ATWOOD DR FL 1
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-4267
Mailing Address - Country:US
Mailing Address - Phone:413-586-1601
Mailing Address - Fax:413-923-9304
Practice Address - Street 1:22 ATWOOD DR FL 1
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-4267
Practice Address - Country:US
Practice Address - Phone:413-586-1601
Practice Address - Fax:413-923-9304
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education