Healthcare Provider Details

I. General information

NPI: 1093379059
Provider Name (Legal Business Name): LUBASI KAMUTI SR. RN, PHN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

726 2ND ST NE
MINNEAPOLIS MN
55413-1662
US

IV. Provider business mailing address

726 2ND ST NE
MINNEAPOLIS MN
55413-1662
US

V. Phone/Fax

Practice location:
  • Phone: 763-230-0737
  • Fax: 651-229-5399
Mailing address:
  • Phone: 612-230-0737
  • Fax: 651-229-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number2471610
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: