Healthcare Provider Details

I. General information

NPI: 1295303386
Provider Name (Legal Business Name): KEMUNTO MOKORA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 JEFFERSON AVE
TOLEDO OH
43604-1004
US

IV. Provider business mailing address

313 JEFFERSON AVE
TOLEDO OH
43604-1004
US

V. Phone/Fax

Practice location:
  • Phone: 419-720-7883
  • Fax:
Mailing address:
  • Phone: 419-720-7883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704393156APP22
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0027696
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0027696
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number0027696
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: