Healthcare Provider Details

I. General information

NPI: 1073258752
Provider Name (Legal Business Name): MUSA MAWANDA APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 11/08/2024
Certification Date: 10/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 STEVE DRIVE
RUSSELL SPRINGS KY
42642-4622
US

IV. Provider business mailing address

PO BOX 1080
BURKESVILLE KY
42717-1080
US

V. Phone/Fax

Practice location:
  • Phone: 270-866-3161
  • Fax: 270-866-3163
Mailing address:
  • Phone: 270-864-1472
  • Fax: 270-864-1693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4016790
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: