Provider Demographics
NPI:1255008447
Name:MUKAMUKIZA, CLARISSE
Entity Type:Individual
Prefix:
First Name:CLARISSE
Middle Name:
Last Name:MUKAMUKIZA
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 1:122 11TH ST # 200
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01850-2102
Mailing Address - Country:US
Mailing Address - Phone:857-204-0573
Mailing Address - Fax:
Practice Address - Street 1:122 11TH ST # 200
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01850-2102
Practice Address - Country:US
Practice Address - Phone:857-204-0573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1972467363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care