Provider Demographics
NPI:1811578040
Name:BANDA, GRETHA NGOMA
Entity Type:Individual
Prefix:
First Name:GRETHA
Middle Name:NGOMA
Last Name:BANDA
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 1:2941 LITTLE STREAM CT
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-8501
Mailing Address - Country:US
Mailing Address - Phone:919-593-6206
Mailing Address - Fax:
Practice Address - Street 1:2941 LITTLE STREAM CT
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-8501
Practice Address - Country:US
Practice Address - Phone:919-593-6206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020129050363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily