Provider Demographics
NPI:1497942643
Name:MUMBA, ENID LWIINDI
Entity Type:Individual
Prefix:
First Name:ENID
Middle Name:LWIINDI
Last Name:MUMBA
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 1:1013 111TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4519
Mailing Address - Country:US
Mailing Address - Phone:763-572-3707
Mailing Address - Fax:763-862-7438
Practice Address - Street 1:1013 111TH AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4519
Practice Address - Country:US
Practice Address - Phone:763-572-3707
Practice Address - Fax:763-862-7438
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL-056770-5164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse