Provider Demographics
NPI:1376114009
Name:KONGO, DAMARIS W (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:DAMARIS
Middle Name:W
Last Name:KONGO
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:DAMARIS
Other - Middle Name:W
Other - Last Name:KONGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:39 ALLISON LN
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-9201
Mailing Address - Country:US
Mailing Address - Phone:413-530-7318
Mailing Address - Fax:
Practice Address - Street 1:39 ALLISON LN
Practice Address - Street 2:
Practice Address - City:LUDLOW
Practice Address - State:MA
Practice Address - Zip Code:01056-9201
Practice Address - Country:US
Practice Address - Phone:413-530-7318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-03
Last Update Date:2024-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN270089163WC1500X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS31366290OtherDRIVERS LISENCE
MA00000000000OtherSOCIAL SECURITY