Provider Demographics
NPI:1942703228
Name:AWASOM-NKIMBENG, KHEN NUDORU
Entity Type:Individual
Prefix:
First Name:KHEN
Middle Name:NUDORU
Last Name:AWASOM-NKIMBENG
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 1:1165 MIDDLESEX ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01851-1240
Mailing Address - Country:US
Mailing Address - Phone:978-328-8050
Mailing Address - Fax:
Practice Address - Street 1:1165B MIDDLESEX ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01851-1240
Practice Address - Country:US
Practice Address - Phone:978-328-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA376J00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker