Provider Demographics
NPI:1407302789
Name:MWANIKI, MARK (RN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MWANIKI
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E SPRING VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-0000
Mailing Address - Country:US
Mailing Address - Phone:781-267-0291
Mailing Address - Fax:
Practice Address - Street 1:1100 E SPRING VALLEY DR
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-0000
Practice Address - Country:US
Practice Address - Phone:781-267-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2281663163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse