Provider Demographics
NPI:1063950632
Name:MOUNKAILA, SOUMANA
Entity type:Individual
Prefix:MR
First Name:SOUMANA
Middle Name:
Last Name:MOUNKAILA
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 1:1975 BIRCHALL AVE APT 8E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-2894
Mailing Address - Country:US
Mailing Address - Phone:646-316-0778
Mailing Address - Fax:
Practice Address - Street 1:1975 BIRCHALL AVE
Practice Address - Street 2:APT 8E
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-2890
Practice Address - Country:US
Practice Address - Phone:646-316-0778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339568-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily