Provider Demographics
NPI:1376930032
Name:DOUMBIA, MACOURA LEILA
Entity Type:Individual
Prefix:
First Name:MACOURA
Middle Name:LEILA
Last Name:DOUMBIA
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 1:675 MORRIS AVE APT 5Q
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-4787
Mailing Address - Country:US
Mailing Address - Phone:917-495-6665
Mailing Address - Fax:
Practice Address - Street 1:675 MORRIS AVE APT 5Q
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-4787
Practice Address - Country:US
Practice Address - Phone:917-495-6665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321035164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse