Provider Demographics
NPI:1558068064
Name:MOKOENA, LYDIA ASSO
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:ASSO
Last Name:MOKOENA
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 1:216 5TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-5779
Mailing Address - Country:US
Mailing Address - Phone:774-329-6133
Mailing Address - Fax:
Practice Address - Street 1:216 5TH ST APT B
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-5779
Practice Address - Country:US
Practice Address - Phone:774-329-6133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN97533164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty