Healthcare Provider Details

I. General information

NPI: 1780371260
Provider Name (Legal Business Name): MIBRAWELL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 04/24/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 FOREST ST STE 262
MARLBOROUGH MA
01752-3195
US

IV. Provider business mailing address

67 FOREST ST STE 262
MARLBOROUGH MA
01752-3195
US

V. Phone/Fax

Practice location:
  • Phone: 508-301-3889
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. CLAIRE WAKULYAKA
Title or Position: NURSE PRACTITIONER
Credential: DNP
Phone: 508-301-3889