Provider Demographics
NPI:1437848728
Name:MWANGI, BONIFACE
Entity Type:Individual
Prefix:MR
First Name:BONIFACE
Middle Name:
Last Name:MWANGI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11137 FILLMORE ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4524
Mailing Address - Country:US
Mailing Address - Phone:165-123-5694
Mailing Address - Fax:
Practice Address - Street 1:11137 FILLMORE ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4524
Practice Address - Country:US
Practice Address - Phone:165-123-5694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR193717-2163WG0000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice