Provider Demographics
NPI:1619099090
Name:MADUKE, MUCHANETA (OTR, CHT)
Entity Type:Individual
Prefix:
First Name:MUCHANETA
Middle Name:
Last Name:MADUKE
Suffix:
Gender:F
Credentials:OTR, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5360 JACKSON DR STE 110
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3012
Mailing Address - Country:US
Mailing Address - Phone:619-667-7000
Mailing Address - Fax:
Practice Address - Street 1:5360 JACKSON DR STE 110
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3012
Practice Address - Country:US
Practice Address - Phone:619-667-7000
Practice Address - Fax:619-667-4315
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4565225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1023103330OtherNPI NUMBER