Provider Demographics
NPI:1417567579
Name:MUSSAU, DOMIANO MUTUKU (RN)
Entity Type:Individual
Prefix:MR
First Name:DOMIANO
Middle Name:MUTUKU
Last Name:MUSSAU
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 1:806 AMERICAN AVE
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93245-9166
Mailing Address - Country:US
Mailing Address - Phone:951-496-2214
Mailing Address - Fax:
Practice Address - Street 1:806 AMERICAN AVE
Practice Address - Street 2:
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93245-9166
Practice Address - Country:US
Practice Address - Phone:951-496-2214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA812291163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical