Provider Demographics
NPI:1043955206
Name:CLARK-MBURUNGA, ALEXANDRIA H
Entity Type:Individual
Prefix:MRS
First Name:ALEXANDRIA
Middle Name:H
Last Name:CLARK-MBURUNGA
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 1:849 6TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-4193
Mailing Address - Country:US
Mailing Address - Phone:313-400-4369
Mailing Address - Fax:
Practice Address - Street 1:849 6TH ST APT B
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-4193
Practice Address - Country:US
Practice Address - Phone:313-400-4369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care