Provider Demographics
NPI:1104410331
Name:BULAMBO, MOSES (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MOSES
Middle Name:
Last Name:BULAMBO
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 W 2ND ST STE 5
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4671
Mailing Address - Country:US
Mailing Address - Phone:575-840-4888
Mailing Address - Fax:
Practice Address - Street 1:918 W AVENUE D
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-3808
Practice Address - Country:US
Practice Address - Phone:575-425-6045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-28
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM626672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry