Provider Demographics
NPI:1265982714
Name:WANGAMATI, BERNARD (LPN)
Entity type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:
Last Name:WANGAMATI
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 SUFFIELD ST
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-2902
Mailing Address - Country:US
Mailing Address - Phone:571-340-5812
Mailing Address - Fax:
Practice Address - Street 1:917 SUFFIELD ST
Practice Address - Street 2:
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001-2902
Practice Address - Country:US
Practice Address - Phone:571-340-5812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-08
Last Update Date:2016-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN87881164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse