Provider Demographics
NPI:1215697214
Name:BONGAY, ISATTA
Entity type:Individual
Prefix:
First Name:ISATTA
Middle Name:
Last Name:BONGAY
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 1:7777 FAWN MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43085-5816
Mailing Address - Country:US
Mailing Address - Phone:978-337-7736
Mailing Address - Fax:
Practice Address - Street 1:7777 FAWN MEADOW CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43085-5816
Practice Address - Country:US
Practice Address - Phone:978-337-7736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-19
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0426225Medicaid