Healthcare Provider Details

I. General information

NPI: 1336365337
Provider Name (Legal Business Name): BANDU IYESATA KAIFA-MUSTAPHA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 CONNECTICUT DR STE 5
BURLINGTON NJ
08016-4177
US

IV. Provider business mailing address

3108 SMOKE HOUSE CT
FREEHOLD NJ
07728-9159
US

V. Phone/Fax

Practice location:
  • Phone: 800-950-6066
  • Fax:
Mailing address:
  • Phone: 732-845-1454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NO10835300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: