Healthcare Provider Details

I. General information

NPI: 1588146013
Provider Name (Legal Business Name): GISELLE MUMAYAMONA BWENSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2018
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 HAWTHORNE LN
YOUNGSVILLE NC
27596-2083
US

IV. Provider business mailing address

8012 WILLOWGLEN DR
RALEIGH NC
27616-3324
US

V. Phone/Fax

Practice location:
  • Phone: 919-400-1181
  • Fax:
Mailing address:
  • Phone: 919-400-1181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: