Provider Demographics
NPI:1215411988
Name:MUTAMBAIE, MBOMBO
Entity Type:Individual
Prefix:
First Name:MBOMBO
Middle Name:
Last Name:MUTAMBAIE
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 1:1822 SOTOGRANDE BLVD APT 1403
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-8838
Mailing Address - Country:US
Mailing Address - Phone:817-939-0987
Mailing Address - Fax:
Practice Address - Street 1:1822 SOTOGRANDE BLVD APT 1403
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-8838
Practice Address - Country:US
Practice Address - Phone:817-939-0987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX187138164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse