Provider Demographics
NPI:1780371260
Name:MIBRAWELL LLC
Entity type:Organization
Organization Name:MIBRAWELL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAIRE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAKULYAKA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:508-301-3889
Mailing Address - Street 1:67 FOREST ST STE 262
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-3195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 FOREST ST STE 262
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-3195
Practice Address - Country:US
Practice Address - Phone:508-301-3889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty