MEDICARE: MRS. LUCY CHANSA MUKUKA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	A00185476	MD
2	374700000X	Technician	MT0155913	MD
3	376K00000X	Nurse's Aide	A00185476	MD

General Provider Information

NPI Number	:	1154012136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LUCY CHANSA MUKUKA

Provider Business Mailing Address
First Line	:	12217 VILLAGE SQUARE TER APT 401
Second Line	:
City	:	ROCKVILLE
State	:	MD
Zip	:	20852-1922
Country	:	US
Telephone Number	:	240-205-9408
Fax Number	:

Provider Business Practice Location Address
First Line	:	3701 CONNECTICUT AVE NW STE 1
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20008-4500
Country	:	US
Telephone Number	:	240-205-9408
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2023
Last Update Date	:	05/19/2023

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