Provider Demographics
NPI:1962160838
Name:OMON-UKPEBOR, MARGARET (CNP)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:
Last Name:OMON-UKPEBOR
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MORAINE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-3664
Mailing Address - Country:US
Mailing Address - Phone:617-309-7715
Mailing Address - Fax:
Practice Address - Street 1:170 MORTON ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3735
Practice Address - Country:US
Practice Address - Phone:617-522-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN266084363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner