Provider Demographics
NPI:1477008001
Name:MUTONGERWA, JEANNE
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:MUTONGERWA
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 1:4040 S EASTERN AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-0854
Mailing Address - Country:US
Mailing Address - Phone:702-463-0300
Mailing Address - Fax:
Practice Address - Street 1:4040 S EASTERN AVE STE 300
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-0854
Practice Address - Country:US
Practice Address - Phone:702-463-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN205543164X00000X
NV838925163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No164X00000XNursing Service ProvidersLicensed Vocational Nurse