Provider Demographics
NPI:1912572934
Name:BANGURA, FATU
Entity Type:Individual
Prefix:
First Name:FATU
Middle Name:
Last Name:BANGURA
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 1:65-67 MELVILLE PLACE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111
Mailing Address - Country:US
Mailing Address - Phone:862-777-3526
Mailing Address - Fax:
Practice Address - Street 1:65-67 MELVILLE PLACE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111
Practice Address - Country:US
Practice Address - Phone:862-777-3526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No251X00000XAgenciesSupports Brokerage
No305S00000XManaged Care OrganizationsPoint of Service