Provider Demographics
NPI:1376971630
Name:KANYONGO, CONCILLIA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:CONCILLIA
Middle Name:
Last Name:KANYONGO
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 FOREST EDGE DR
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-1015
Mailing Address - Country:US
Mailing Address - Phone:614-446-0166
Mailing Address - Fax:
Practice Address - Street 1:4075 FOREST EDGE DR
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-1015
Practice Address - Country:US
Practice Address - Phone:614-446-0166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH397097163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH397097Medicare Oscar/Certification