Healthcare Provider Details

I. General information

NPI: 1306259718
Provider Name (Legal Business Name): OMAKA MOKAMBE RN, BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2318 W FALLCREEK CT
GRAND FORKS ND
58201-5253
US

IV. Provider business mailing address

2318 W FALLCREEK CT
GRAND FORKS ND
58201-5253
US

V. Phone/Fax

Practice location:
  • Phone: 248-790-5926
  • Fax:
Mailing address:
  • Phone: 248-790-5926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR49699
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR49699
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR49699
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: