Provider Demographics
NPI:1912782194
Name:NGOMA, LELO THEO (NP)
Entity Type:Individual
Prefix:MR
First Name:LELO
Middle Name:THEO
Last Name:NGOMA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:LELO
Other - Middle Name:THEO
Other - Last Name:NGOMA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:187 COALYARD DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-7373
Mailing Address - Country:US
Mailing Address - Phone:919-720-9978
Mailing Address - Fax:
Practice Address - Street 1:187 COALYARD DR
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-7373
Practice Address - Country:US
Practice Address - Phone:919-720-9978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNGOM-7LKIK363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily