Provider Demographics
NPI:1053693127
Name:MUTOMBO, CLARISSE MASENGO
Entity type:Individual
Prefix:
First Name:CLARISSE
Middle Name:MASENGO
Last Name:MUTOMBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 KLATTENHOFF LN
Mailing Address - Street 2:3204
Mailing Address - City:HUTTO
Mailing Address - State:TX
Mailing Address - Zip Code:78634-4601
Mailing Address - Country:US
Mailing Address - Phone:917-355-3458
Mailing Address - Fax:
Practice Address - Street 1:150 KLATTENHOFF LN
Practice Address - Street 2:3204
Practice Address - City:HUTTO
Practice Address - State:TX
Practice Address - Zip Code:78634-4601
Practice Address - Country:US
Practice Address - Phone:917-355-3458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No171W00000XOther Service ProvidersContractor
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner