Provider Demographics
NPI:1851862551
Name:NGOMBABU, MAMI (RN)
Entity Type:Individual
Prefix:
First Name:MAMI
Middle Name:
Last Name:NGOMBABU
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LONG WHARF DR STE 321
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5946
Mailing Address - Country:US
Mailing Address - Phone:203-781-4600
Mailing Address - Fax:203-781-4624
Practice Address - Street 1:1 LONG WHARF DR STE 321
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5946
Practice Address - Country:US
Practice Address - Phone:203-781-4600
Practice Address - Fax:203-781-4624
Is Sole Proprietor?:No
Enumeration Date:2018-12-07
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT136997163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004082260Medicaid
CT008001325Medicaid
CT008022622Medicaid