Provider Demographics
NPI:1801656566
Name:SSENABULYA, MICHEAL
Entity type:Individual
Prefix:
First Name:MICHEAL
Middle Name:
Last Name:SSENABULYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 GORHAM ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-4023
Mailing Address - Country:US
Mailing Address - Phone:508-904-2904
Mailing Address - Fax:
Practice Address - Street 1:658 GORHAM ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-4023
Practice Address - Country:US
Practice Address - Phone:508-904-2904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN90294164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse