Provider Demographics
NPI:1841940541
Name:MBURU, BRENDA N
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:N
Last Name:MBURU
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 1:1399 WESTWARD DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-4079
Mailing Address - Country:US
Mailing Address - Phone:678-468-5180
Mailing Address - Fax:
Practice Address - Street 1:1399 WESTWARD DR SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-4079
Practice Address - Country:US
Practice Address - Phone:678-468-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033-R-1911374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003228008AMedicaid