Provider Demographics
NPI:1063808814
Name:MOFUNANYA, PHILOMENA NGOZI
Entity type:Individual
Prefix:
First Name:PHILOMENA
Middle Name:NGOZI
Last Name:MOFUNANYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3965 SEDGWICK AVE APT 10E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-3106
Mailing Address - Country:US
Mailing Address - Phone:718-496-1654
Mailing Address - Fax:
Practice Address - Street 1:3965 SEDGWICK AVE
Practice Address - Street 2:#10E
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-3111
Practice Address - Country:US
Practice Address - Phone:718-496-1654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6137701163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse