Basic Information
| Provider Information | |||||||||
| NPI: | 1821639634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOUEMOU | ||||||||
| FirstName: | BEATRICE | ||||||||
| MiddleName: | MOUGA | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 W BURNSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104534015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184831270 | ||||||||
| FaxNumber: | 7182940783 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 W BURNSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104534015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184831270 | ||||||||
| FaxNumber: | 7182940783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2019 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2019048450 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | F346954-1 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.