Provider Demographics
NPI:1104663608
Name:JABANGWE, TRYSELDAH MUTSAGO
Entity type:Individual
Prefix:DR
First Name:TRYSELDAH
Middle Name:MUTSAGO
Last Name:JABANGWE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRYSELDAH
Other - Middle Name:
Other - Last Name:MUSIKAVANHU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4301 W MARKHAM ST # 529
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7101
Mailing Address - Country:US
Mailing Address - Phone:469-571-1048
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST # 529
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:469-571-1048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX866521163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine