Provider Demographics
NPI:1144729344
Name:MOUGARBEL, RANDA
Entity type:Individual
Prefix:
First Name:RANDA
Middle Name:
Last Name:MOUGARBEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 LIBBY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2949
Mailing Address - Country:US
Mailing Address - Phone:508-894-0400
Mailing Address - Fax:
Practice Address - Street 1:25 LIBBY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2949
Practice Address - Country:US
Practice Address - Phone:508-894-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-03
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2272611163WX0800X, 363LA2200X
NY309093363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WX0800XNursing Service ProvidersRegistered NurseOrthopedic