Provider Demographics
NPI:1538832241
Name:MUDIMBA, ANTONINA ADHIAMBO (FNP)
Entity type:Individual
Prefix:MRS
First Name:ANTONINA
Middle Name:ADHIAMBO
Last Name:MUDIMBA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 TAYLOR AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-8315
Mailing Address - Country:US
Mailing Address - Phone:443-797-6456
Mailing Address - Fax:
Practice Address - Street 1:1045 TAYLOR AVE STE 112
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-8315
Practice Address - Country:US
Practice Address - Phone:443-797-6456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR227275363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty