Provider Demographics
NPI:1093708869
Name:MUMUNEY, KUDIRAT (NP)
Entity Type:Individual
Prefix:
First Name:KUDIRAT
Middle Name:
Last Name:MUMUNEY
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 1:124 MCELROY RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4317
Mailing Address - Country:US
Mailing Address - Phone:678-817-0688
Mailing Address - Fax:
Practice Address - Street 1:315 S 9TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4111
Practice Address - Country:US
Practice Address - Phone:770-229-3048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN146636363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP41499Medicare UPIN