Provider Demographics
NPI:1760351720
Name:MWIKISA-KELLY, TABO (RN)
Entity type:Individual
Prefix:DR
First Name:TABO
Middle Name:
Last Name:MWIKISA-KELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 KOCH RD
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1264
Mailing Address - Country:US
Mailing Address - Phone:862-438-2099
Mailing Address - Fax:
Practice Address - Street 1:1240 S ELISEO DR STE 200
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2028
Practice Address - Country:US
Practice Address - Phone:862-438-2099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-30
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95119319163WU0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WU0100XNursing Service ProvidersRegistered NurseUrology