Healthcare Provider Details

I. General information

NPI: 1821929084
Provider Name (Legal Business Name): LORRAINE MUKONA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 BROADWAY STE 350
FORT WAYNE IN
46802-1412
US

IV. Provider business mailing address

750 BROADWAY STE 250
FORT WAYNE IN
46802-1412
US

V. Phone/Fax

Practice location:
  • Phone: 260-423-2675
  • Fax: 260-969-2905
Mailing address:
  • Phone: 260-422-6573
  • Fax: 260-399-4242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11024957A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: