Individual
MR. GALLUS LEREH FOTABONG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
41 HARVEST ST, LYNN, MA 01902-1122
(781) 244-8473
Mailing address
41 HARVEST ST, LYNN, MA 01902-1122
(781) 244-8473
Taxonomy
Speciality
Code
Description
License number
State
363LG0600X
Gerontology Nurse Practitioner
Primary
AG11210066
MA
Other
Enumeration date
11/17/2021
Last updated
11/17/2021
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