MEDICARE: NYAKUME DUP

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1265092563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NYAKUME DUP

Provider Business Mailing Address
First Line	:	237 S PEARL ST
Second Line	:
City	:	ALBERT LEA
State	:	MN
Zip	:	56007-2644
Country	:	US
Telephone Number	:	507-369-4489
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 E MAIN ST STE 1
Second Line	:
City	:	MANKATO
State	:	MN
Zip	:	56001-3574
Country	:	US
Telephone Number	:	507-345-7012
Fax Number	:

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

Provider Enumeration Date	:	06/18/2019
Last Update Date	:	06/18/2019

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Directions to “ NYAKUME DUP ” Practice Location

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