Provider Demographics
NPI:1417582628
Name:OMBOGO, STACY MORAA
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MORAA
Last Name:OMBOGO
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 1:7166 N FRUIT AVE APT 120
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-0744
Mailing Address - Country:US
Mailing Address - Phone:559-972-7489
Mailing Address - Fax:
Practice Address - Street 1:7166 N FRUIT AVE APT 120
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-0744
Practice Address - Country:US
Practice Address - Phone:559-972-7489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-08
Last Update Date:2020-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA282878164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse