Provider Demographics
NPI:1831661370
Name:MANDELA, MAMIE MUKUNDI (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MAMIE
Middle Name:MUKUNDI
Last Name:MANDELA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 E 218TH ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-2402
Mailing Address - Country:US
Mailing Address - Phone:310-702-5392
Mailing Address - Fax:310-518-2585
Practice Address - Street 1:1413 E 218TH ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-2402
Practice Address - Country:US
Practice Address - Phone:310-702-5392
Practice Address - Fax:310-518-2585
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-21
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010871363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner