Provider Demographics
NPI:1689257594
Name:NYABOGA, RISPER KEMUNTO
Entity Type:Individual
Prefix:
First Name:RISPER
Middle Name:KEMUNTO
Last Name:NYABOGA
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 1:12404 ALDER ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-4801
Mailing Address - Country:US
Mailing Address - Phone:952-200-7691
Mailing Address - Fax:
Practice Address - Street 1:12404 ALDER ST NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-4801
Practice Address - Country:US
Practice Address - Phone:952-200-7691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-186631-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse