Provider Demographics
NPI:1407528714
Name:NYAMAYARO, PRUDENCE ADLAIDE
Entity Type:Individual
Prefix:
First Name:PRUDENCE
Middle Name:ADLAIDE
Last Name:NYAMAYARO
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 1:1201 1ST ST SW APT 8
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-0369
Mailing Address - Country:US
Mailing Address - Phone:612-327-8018
Mailing Address - Fax:
Practice Address - Street 1:BLUESTEM CENTO
Practice Address - Street 2:124 ELTON HILLS LN NE
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901
Practice Address - Country:US
Practice Address - Phone:507-282-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician