Healthcare Provider Details

I. General information

NPI: 1104663608
Provider Name (Legal Business Name): DR. TRYSELDAH MUTSAGO JABANGWE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRYSELDAH MUSIKAVANHU

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST # 529
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

4301 W MARKHAM ST # 529
LITTLE ROCK AR
72205-7101
US

V. Phone/Fax

Practice location:
  • Phone: 469-571-1048
  • Fax:
Mailing address:
  • Phone: 469-571-1048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number866521
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1204174
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: