Provider Demographics
NPI:1447954342
Name:MUTISYA, JANE MUTHEU (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:MUTHEU
Last Name:MUTISYA
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 W PLEASANT RUN RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-1114
Mailing Address - Country:US
Mailing Address - Phone:469-297-5321
Mailing Address - Fax:
Practice Address - Street 1:2600 W PLEASANT RUN RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75146-1114
Practice Address - Country:US
Practice Address - Phone:469-297-5321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1077660363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care