Healthcare Provider Details

I. General information

NPI: 1679490981
Provider Name (Legal Business Name): NGINA MUTHUSI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 E MADISON ST
SOUTH BEND IN
46617-2322
US

IV. Provider business mailing address

330 LAKEVIEW DR
GOSHEN IN
46528-7000
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-1234
  • Fax: 574-537-2652
Mailing address:
  • Phone: 574-533-1234
  • Fax: 574-537-2652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number88003363A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: