Provider Demographics
NPI:1083032981
Name:MUTANGA, EDELINE (NP)
Entity Type:Individual
Prefix:MRS
First Name:EDELINE
Middle Name:
Last Name:MUTANGA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28326 JONSPORT LN
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-1845
Mailing Address - Country:US
Mailing Address - Phone:315-534-9441
Mailing Address - Fax:
Practice Address - Street 1:111 VISION PARK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-3003
Practice Address - Country:US
Practice Address - Phone:713-714-1399
Practice Address - Fax:713-389-5798
Is Sole Proprietor?:No
Enumeration Date:2014-03-29
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX841378363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily