Provider Demographics
NPI:1760955660
Name:MUMFORD, TAHJI
Entity Type:Individual
Prefix:
First Name:TAHJI
Middle Name:
Last Name:MUMFORD
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 1:25 BRAINTREE HILL PARK STE 101
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-8715
Mailing Address - Country:US
Mailing Address - Phone:781-971-5019
Mailing Address - Fax:
Practice Address - Street 1:454 BROADWAY
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3034
Practice Address - Country:US
Practice Address - Phone:617-665-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2301648163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse