Provider Demographics
NPI:1184350373
Name:MOUNCHIRANE, AJARA MBOUOMBOUO
Entity type:Individual
Prefix:
First Name:AJARA
Middle Name:MBOUOMBOUO
Last Name:MOUNCHIRANE
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 1:1010 SKYLINE DR APT 10
Mailing Address - Street 2:
Mailing Address - City:DRACUT
Mailing Address - State:MA
Mailing Address - Zip Code:01826-6140
Mailing Address - Country:US
Mailing Address - Phone:978-332-2502
Mailing Address - Fax:
Practice Address - Street 1:1010 SKYLINE DR APT 10
Practice Address - Street 2:
Practice Address - City:DRACUT
Practice Address - State:MA
Practice Address - Zip Code:01826-6140
Practice Address - Country:US
Practice Address - Phone:978-332-2502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAG07220153363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner