Healthcare Provider Details

I. General information

NPI: 1720792302
Provider Name (Legal Business Name): ROBERT MUTISYA NDAMBUKI CNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 NW SUNRISE DR
PULLMAN WA
99163-2907
US

IV. Provider business mailing address

218 NW SUNRISE DR
PULLMAN WA
99163-2907
US

V. Phone/Fax

Practice location:
  • Phone: 509-592-8273
  • Fax: 509-715-1040
Mailing address:
  • Phone: 509-592-8273
  • Fax: 509-715-1040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number753235
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: