Provider Demographics
NPI:1962148031
Name:KANONI, CLAUDINE NGALULA (AG-NP)
Entity type:Individual
Prefix:
First Name:CLAUDINE
Middle Name:NGALULA
Last Name:KANONI
Suffix:
Gender:F
Credentials:AG-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-3857
Mailing Address - Country:US
Mailing Address - Phone:339-227-9326
Mailing Address - Fax:
Practice Address - Street 1:2 REHABILITATION WAY
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6003
Practice Address - Country:US
Practice Address - Phone:781-935-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAG07220107363LP2300X
MARN276775363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care