Provider Demographics
NPI:1710301304
Name:NDUNGU, JOYCE REGINAH W (NP)
Entity Type:Individual
Prefix:
First Name:JOYCE REGINAH
Middle Name:W
Last Name:NDUNGU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 WASHINGTON STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:315-788-2211
Mailing Address - Fax:315-788-0956
Practice Address - Street 1:513 WASHINGTON STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-788-2211
Practice Address - Fax:315-788-0956
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF338430-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03807274Medicaid