Provider Demographics
NPI:1649892068
Name:GITHIORA, EDWARD KABII
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:KABII
Last Name:GITHIORA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 FAWN FOREST RD
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-0040
Mailing Address - Country:US
Mailing Address - Phone:763-639-6044
Mailing Address - Fax:
Practice Address - Street 1:121 WASHINGTON AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55401
Practice Address - Country:US
Practice Address - Phone:763-639-6044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN210372-7163WP0807X
MN9670363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent