Provider Demographics
NPI:1285401687
Name:MBAMA-MPOLO, LICEMEE
Entity type:Individual
Prefix:
First Name:LICEMEE
Middle Name:
Last Name:MBAMA-MPOLO
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 1:57 FLINTON RUN
Mailing Address - Street 2:
Mailing Address - City:CHURCHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14428-9651
Mailing Address - Country:US
Mailing Address - Phone:585-770-0683
Mailing Address - Fax:
Practice Address - Street 1:1555 LONG POND RD
Practice Address - Street 2:
Practice Address - City:GREECE
Practice Address - State:NY
Practice Address - Zip Code:14626-4164
Practice Address - Country:US
Practice Address - Phone:585-368-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY797276163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn