Basic Information
| Provider Information | |||||||||
| NPI: | 1942434188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONGAH | ||||||||
| FirstName: | FRANCIS | ||||||||
| MiddleName: | MORIE | ||||||||
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| Credential: | APN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 COOLIDGE ST | ||||||||
| Address2: | |||||||||
| City: | IRVINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071111108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8628492854 | ||||||||
| FaxNumber: | 8628492854 | ||||||||
| Practice Location | |||||||||
| Address1: | 741 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071044309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734831300 | ||||||||
| FaxNumber: | 9736761396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2009 | ||||||||
| LastUpdateDate: | 05/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 37LC00230300 | NJ | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 363LA2200X | 26NJ00132000 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.