Provider Demographics
NPI:1417426636
Name:NANYAME, MALBA
Entity Type:Individual
Prefix:
First Name:MALBA
Middle Name:
Last Name:NANYAME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 BAYCHESTER AVE APT 5B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-4457
Mailing Address - Country:US
Mailing Address - Phone:646-875-9290
Mailing Address - Fax:
Practice Address - Street 1:600 BAYCHESTER AVE APT 5B
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-4457
Practice Address - Country:US
Practice Address - Phone:646-875-9290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF342961363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily