Provider Demographics
NPI:1841757374
Name:MUTHONI, ROSE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:MUTHONI
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 1:1904 RICHLAND AVE BLDG A
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-4562
Mailing Address - Country:US
Mailing Address - Phone:209-300-8800
Mailing Address - Fax:
Practice Address - Street 1:1409 DAISY WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-1415
Practice Address - Country:US
Practice Address - Phone:510-878-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA701328164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse