Provider Demographics
NPI:1205334927
Name:MBURU, MARTHA WAHU (FNP-C)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:WAHU
Last Name:MBURU
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17747 TALLYHO DR E
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1040
Mailing Address - Country:US
Mailing Address - Phone:574-707-5898
Mailing Address - Fax:
Practice Address - Street 1:19819 154TH ST E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-7482
Practice Address - Country:US
Practice Address - Phone:574-707-5898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-28
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61267437163W00000X
IN0202917363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARN61267437OtherDOH