Provider Demographics
NPI:1639888092
Name:MAMBO, MIRABEL TIBUJI
Entity Type:Individual
Prefix:MRS
First Name:MIRABEL
Middle Name:TIBUJI
Last Name:MAMBO
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 1:19097 BALDWIN ST NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-2813
Mailing Address - Country:US
Mailing Address - Phone:763-328-4738
Mailing Address - Fax:
Practice Address - Street 1:19097 BALDWIN ST NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-2813
Practice Address - Country:US
Practice Address - Phone:763-328-4738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9433363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty