Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | SP008515 | PA |
NPI | 1003964586 |
---|---|
Provider Name | Faith Mutale |
First Address | Philadelphia, PA 19104-4206 |
Second Address | Philadelphia, PA 19104-4206 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/01/2007 |
Last Update Date | 15/03/2011 |