Healthcare Provider Details

I. General information

NPI: 1902442874
Provider Name (Legal Business Name): RAISSA MUTUYIMANA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 QUAKER LN # C2-4
WARWICK RI
02886-0159
US

IV. Provider business mailing address

30 W MONROE ST STE 1200
CHICAGO IL
60603-2420
US

V. Phone/Fax

Practice location:
  • Phone: 401-233-5051
  • Fax: 401-372-3445
Mailing address:
  • Phone: 312-733-9730
  • Fax: 773-866-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP021157
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: