Provider Demographics
NPI:1437880648
Name:LANG, MIMEROSE P
Entity Type:Individual
Prefix:
First Name:MIMEROSE
Middle Name:P
Last Name:LANG
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 1:712 E 27TH ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-2217
Mailing Address - Country:US
Mailing Address - Phone:646-591-9964
Mailing Address - Fax:
Practice Address - Street 1:712 E 27TH ST APT 3A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-2217
Practice Address - Country:US
Practice Address - Phone:718-647-2443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-19
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ013180600363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health