Provider Demographics
NPI:1063168284
Name:MUNGAL, KEISHA (FNP)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:MUNGAL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 WASHINGTON ST, SOUTH 7
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111
Mailing Address - Country:US
Mailing Address - Phone:617-636-1227
Mailing Address - Fax:
Practice Address - Street 1:800 WASHINGTON ST, SOUTH 7
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111
Practice Address - Country:US
Practice Address - Phone:617-636-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAF002221067363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily