Healthcare Provider Details

I. General information

NPI: 1902634264
Provider Name (Legal Business Name): NAOMI KIYONDI MOKUA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6204 MAYFIELD AVE
LA CRESCENTA CA
91214-2371
US

IV. Provider business mailing address

6204 MAYFIELD AVE
LA CRESCENTA CA
91214-2371
US

V. Phone/Fax

Practice location:
  • Phone: 713-498-4883
  • Fax:
Mailing address:
  • Phone: 713-498-4883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95388589
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: