Provider Demographics
NPI:1437888096
Name:MBIATEM, MAYBELLE
Entity Type:Individual
Prefix:
First Name:MAYBELLE
Middle Name:
Last Name:MBIATEM
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 1:1 W FOSTER ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-3847
Mailing Address - Country:US
Mailing Address - Phone:617-935-8829
Mailing Address - Fax:
Practice Address - Street 1:1 W FOSTER ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3847
Practice Address - Country:US
Practice Address - Phone:617-935-8829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2266707363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health