Provider Demographics
NPI:1598523995
Name:NGOMA, NELLY J (LPN)
Entity Type:Individual
Prefix:
First Name:NELLY
Middle Name:J
Last Name:NGOMA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0463
Mailing Address - Country:US
Mailing Address - Phone:773-816-9815
Mailing Address - Fax:
Practice Address - Street 1:140 INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0463
Practice Address - Country:US
Practice Address - Phone:773-816-9815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDL17749164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse