Healthcare Provider Details

I. General information

NPI: 1104225341
Provider Name (Legal Business Name): GRACE MBUYA PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 STAFFORD ST
WORCESTER MA
01603-1457
US

IV. Provider business mailing address

21 SW CUTOFF
NORTHBOROUGH MA
01532-2135
US

V. Phone/Fax

Practice location:
  • Phone: 508-344-7530
  • Fax:
Mailing address:
  • Phone: 508-344-7530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number284646
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN284646
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number316951
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN284646
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: