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General NPI Number Information
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NPI Number | 1093373037
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Entity Type | Individual
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Provider Name | MARTHA MUKWADA NP-C/PMHNP
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Gender | Female
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Dates
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Enumeration Date | 06/04/2019
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Last Update Date | 11/19/2024
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Provider Practice Location Address
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Address Line | 220 W CONGRESS ST
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City | DETROIT
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State | MI
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Zip | 48226-3289
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Country | US
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Telephone | 269-267-9763
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Fax |
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Provider Business Mailing Address
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Address Line | 5657 SPRINGRIDGE ST
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City | PORTAGE
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State | MI
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Zip | 49024-1271
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Country | US
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Telephone | 692-677-9763
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 19133140548
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 4704259350
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 4704259350
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License Number State | MI
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