Healthcare Provider Details

I. General information

NPI: 1710624143
Provider Name (Legal Business Name): JOHN GIKUNGU MUTHIGA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

873 S STEMMONS FWY STE 100
LEWISVILLE TX
75067-5351
US

IV. Provider business mailing address

2637 HAMLET GREEN DR
RALEIGH NC
27614-8076
US

V. Phone/Fax

Practice location:
  • Phone: 713-516-3849
  • Fax:
Mailing address:
  • Phone: 919-637-0325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number226171
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1115893
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: