Provider Demographics
NPI:1598587248
Name:MUKWAMUGO, ADELINE
Entity type:Individual
Prefix:
First Name:ADELINE
Middle Name:
Last Name:MUKWAMUGO
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 1:4334 N LOOP 1604 W STE 103
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-3485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4334 N LOOP 1604 W STE 103
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-3485
Practice Address - Country:US
Practice Address - Phone:210-918-8737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY326408164W00000X
TX300870164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse