Provider Demographics
NPI:1821249749
Name:SAM-KPAKRA, MAMANDOMA (RISGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:MAMANDOMA
Middle Name:
Last Name:SAM-KPAKRA
Suffix:
Gender:F
Credentials:RISGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1253 W BLOOMINGFIELD DR
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-2659
Mailing Address - Country:US
Mailing Address - Phone:262-472-8994
Mailing Address - Fax:414-282-2051
Practice Address - Street 1:1253 W BLOOMINGFIELD DR
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-2659
Practice Address - Country:US
Practice Address - Phone:262-472-8994
Practice Address - Fax:414-282-2051
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI153910163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35041400Medicaid