Provider Demographics
NPI:1407661580
Name:MUKUNJURA, ALICE G (APRN, PMHNP)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:G
Last Name:MUKUNJURA
Suffix:
Gender:F
Credentials:APRN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2456 HART DR SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-1564
Mailing Address - Country:US
Mailing Address - Phone:507-319-0291
Mailing Address - Fax:
Practice Address - Street 1:1431 OPUS PL STE 110
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1164
Practice Address - Country:US
Practice Address - Phone:888-279-0002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12459363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health