Provider Demographics
NPI:1134747264
Name:IFEZULUMBA, CONSOLE
Entity type:Individual
Prefix:
First Name:CONSOLE
Middle Name:
Last Name:IFEZULUMBA
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 1:27 ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-5010
Mailing Address - Country:US
Mailing Address - Phone:917-940-8220
Mailing Address - Fax:
Practice Address - Street 1:27 ALBANY ST
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-5010
Practice Address - Country:US
Practice Address - Phone:917-940-8220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337045164W00000X
NY827621163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse