Healthcare Provider Details

I. General information

NPI: 1306780366
Provider Name (Legal Business Name): EDWIN MUTONYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2026
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 PACELLA PARK DR APT 6311
RANDOLPH MA
02368-1795
US

IV. Provider business mailing address

5 PACELLA PARK DR APT 6311
RANDOLPH MA
02368-1795
US

V. Phone/Fax

Practice location:
  • Phone: 781-558-3803
  • Fax: 978-945-1065
Mailing address:
  • Phone: 781-558-3803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN2298821
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: