Provider Demographics
NPI:1427321033
Name:MUKONA, LOICE
Entity type:Individual
Prefix:
First Name:LOICE
Middle Name:
Last Name:MUKONA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 RED PHISTER DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7172
Mailing Address - Country:US
Mailing Address - Phone:317-272-1383
Mailing Address - Fax:
Practice Address - Street 1:1201 N POST RD STE 4
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4225
Practice Address - Country:US
Practice Address - Phone:317-405-8833
Practice Address - Fax:317-672-2398
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28140253A163W00000X
IN71003823363LF0000X
IN71003823A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201052050Medicaid