Provider Demographics
NPI:1760945752
Name:OMOONGEH, MILDRED K (NP)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:K
Last Name:OMOONGEH
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 1:1835 W MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-3046
Mailing Address - Country:US
Mailing Address - Phone:602-230-0777
Mailing Address - Fax:
Practice Address - Street 1:1835 W MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3046
Practice Address - Country:US
Practice Address - Phone:602-230-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX855808163WC0200X
AZ231224363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine