Provider Demographics
NPI:1700378932
Name:MUKASA, LILLIAN T
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:T
Last Name:MUKASA
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 1:5383 SOUTHERN BLVD APT 427
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-7300
Mailing Address - Country:US
Mailing Address - Phone:972-730-0475
Mailing Address - Fax:
Practice Address - Street 1:5383 SOUTHERN BLVD APT 427
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-7300
Practice Address - Country:US
Practice Address - Phone:972-730-0475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX596101163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse