Provider Demographics
NPI:1770987950
Name:NYANGORO, MOURINE J (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MOURINE
Middle Name:J
Last Name:NYANGORO
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:MOURINE
Other - Middle Name:J
Other - Last Name:NYANGORO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:4416 BERTHSTONE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-8721
Mailing Address - Country:US
Mailing Address - Phone:614-475-8476
Mailing Address - Fax:
Practice Address - Street 1:5900 ROCHE DR STE 260B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-3272
Practice Address - Country:US
Practice Address - Phone:614-448-7614
Practice Address - Fax:614-686-2933
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-16
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0030090363L00000X
OH00030090363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner