Provider Demographics
NPI:1609597293
Name:MAINA, DAMARIS WAITHIRA
Entity Type:Individual
Prefix:
First Name:DAMARIS
Middle Name:WAITHIRA
Last Name:MAINA
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 1:76 BAYBERRY DR
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-4965
Mailing Address - Country:US
Mailing Address - Phone:978-726-3109
Mailing Address - Fax:
Practice Address - Street 1:76 BAYBERRY DR
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-4965
Practice Address - Country:US
Practice Address - Phone:978-726-3109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2355140163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9787263109Medicaid