Provider Demographics
NPI:1477289619
Name:MUKORO, SIPHRA NGUM
Entity Type:Individual
Prefix:
First Name:SIPHRA
Middle Name:NGUM
Last Name:MUKORO
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 1:5926 TOMAHAWK ST
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-6757
Mailing Address - Country:US
Mailing Address - Phone:301-675-3515
Mailing Address - Fax:
Practice Address - Street 1:13994 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5087
Practice Address - Country:US
Practice Address - Phone:301-477-2128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR223264363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health