Provider Demographics
NPI:1629567961
Name:MIRUKA, SOPHIAH BOSIBORI
Entity Type:Individual
Prefix:
First Name:SOPHIAH
Middle Name:BOSIBORI
Last Name:MIRUKA
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 1:3002 LEESA DR
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-8115
Mailing Address - Country:US
Mailing Address - Phone:214-604-2009
Mailing Address - Fax:
Practice Address - Street 1:3002 LEESA DR
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-8115
Practice Address - Country:US
Practice Address - Phone:214-604-2009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX315093164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse