Provider Demographics
NPI:1275334351
Name:BAMGBALA, DESOLA-VASILISA (RN)
Entity type:Individual
Prefix:
First Name:DESOLA-VASILISA
Middle Name:
Last Name:BAMGBALA
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 ISLAND HILL AVE UNIT 310
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-6140
Mailing Address - Country:US
Mailing Address - Phone:917-340-6534
Mailing Address - Fax:
Practice Address - Street 1:16 ISLAND HILL AVE UNIT 310
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-6140
Practice Address - Country:US
Practice Address - Phone:917-340-6534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2373211163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health