Provider Demographics
NPI:1073193652
Name:MUKANGU, STEPHANIE NICHOLE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:NICHOLE
Last Name:MUKANGU
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:NICHOLE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:340 BRAMFORD WAY NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1337
Mailing Address - Country:US
Mailing Address - Phone:563-508-4796
Mailing Address - Fax:
Practice Address - Street 1:2994 ATLANTA RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-3655
Practice Address - Country:US
Practice Address - Phone:770-435-2178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN293669363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily