Provider Demographics
NPI:1659748325
Name:YOLI, BONGIWE (OWNER)
Entity Type:Individual
Prefix:
First Name:BONGIWE
Middle Name:
Last Name:YOLI
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 EAST MOUNTAIN ROAD
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706
Mailing Address - Country:US
Mailing Address - Phone:203-558-9490
Mailing Address - Fax:
Practice Address - Street 1:197 WILTON RD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-2334
Practice Address - Country:US
Practice Address - Phone:203-558-9490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health