Provider Demographics
NPI:1306615992
Name:BONIPHACE, ALPHONCE MORANGO
Entity type:Individual
Prefix:
First Name:ALPHONCE
Middle Name:MORANGO
Last Name:BONIPHACE
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 1:5031 S ORCHARD ST APT B
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98467-3667
Mailing Address - Country:US
Mailing Address - Phone:240-615-3791
Mailing Address - Fax:
Practice Address - Street 1:5031 S ORCHARD ST APT B
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98467-3667
Practice Address - Country:US
Practice Address - Phone:240-615-3791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANC61503287163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Single Specialty