Healthcare Provider Details

I. General information

NPI: 1407528714
Provider Name (Legal Business Name): PRUDENCE ADLAIDE NYAMAYARO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLUESTEM CENTO 124 ELTON HILLS LN NE
ROCHESTER MN
55901
US

IV. Provider business mailing address

1201 1ST ST SW APT 8
ROCHESTER MN
55902-0369
US

V. Phone/Fax

Practice location:
  • Phone: 507-282-1009
  • Fax:
Mailing address:
  • Phone: 612-327-8018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: