Healthcare Provider Details

I. General information

NPI: 1750125829
Provider Name (Legal Business Name): MULBAH ZOWAH PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 CHESTER BLVD
RICHMOND IN
47374-1221
US

IV. Provider business mailing address

240 N TILLOTSON AVE
MUNCIE IN
47304-3988
US

V. Phone/Fax

Practice location:
  • Phone: 765-939-2395
  • Fax:
Mailing address:
  • Phone: 765-288-1928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71015626A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: