Provider Demographics
NPI:1871234435
Name:OMBOGO, MARTHA KERUBO
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:KERUBO
Last Name:OMBOGO
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 1:12272 CREVE COEUR RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-1213
Mailing Address - Country:US
Mailing Address - Phone:816-824-1447
Mailing Address - Fax:
Practice Address - Street 1:12272 CREVE COEUR RIDGE CT
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-1213
Practice Address - Country:US
Practice Address - Phone:816-824-1447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022012281363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology