Provider Demographics
NPI:1023725355
Name:MUKIZA, DIVINE NYAMASOSO
Entity type:Individual
Prefix:
First Name:DIVINE
Middle Name:NYAMASOSO
Last Name:MUKIZA
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 1:16630 N 43RD AVE APT 267
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-1543
Mailing Address - Country:US
Mailing Address - Phone:319-383-9411
Mailing Address - Fax:
Practice Address - Street 1:16630 N 43RD AVE APT 267
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-1543
Practice Address - Country:US
Practice Address - Phone:319-383-9411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver