Provider Demographics
NPI:1780219121
Name:NYAMARI, SIMON MOMANYI (RN)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:MOMANYI
Last Name:NYAMARI
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 SOUTHCROSS DR W STE 105
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-7012
Mailing Address - Country:US
Mailing Address - Phone:952-683-1628
Mailing Address - Fax:952-683-1629
Practice Address - Street 1:1705 SOUTHCROSS DR W STE 105
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-7012
Practice Address - Country:US
Practice Address - Phone:952-683-1628
Practice Address - Fax:952-683-1629
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1704787163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA836410600OtherMA CADI WAIVER
MNA116450100OtherCADI WAIVER MA