Mirabel Tibuji Mambo

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

9433 Issued in MN

Practice address

19097 Baldwin St NW
Elk River, MN 55330-2813

Phone

(763) 328-4738

NPI assigned

Nov 15, 2022

Last updated

Nov 15, 2022By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Other, 2022

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Diamond Lake Clinic, P.C.Group PAC ID 8022324664, 12 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: mirabel.mambo.1@32670.direct.athenahealth.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Diamond Lake Clinic, P.C.

  • Health Service Clinic/Center
  • Minneapolis, MN
  • NPI 1740669498

  Multi-Specialty

  Medicare reassignment Care Compare group NPD
• Psych North PLLC

  • Psychiatric/Mental Health Nurse Practitioner
  • Duluth, MN
  • NPI 1760136964

  Multi-Specialty

  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1668470400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1668470400000",
    "number": "1639888092",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "19097 BALDWIN ST NW",
            "city": "ELK RIVER",
            "state": "MN",
            "postal_code": "553302813",
            "telephone_number": "763-328-4738"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19097 BALDWIN ST NW",
            "city": "ELK RIVER",
            "state": "MN",
            "postal_code": "553302813",
            "telephone_number": "763-328-4738"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MAMBO",
        "first_name": "MIRABEL",
        "middle_name": "TIBUJI",
        "name_prefix": "Mrs.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-11-15",
        "last_updated": "2022-11-15",
        "certification_date": "2022-11-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "MN",
            "license": "9433",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Melissa Maccafferty, L.I.C.S.W
• Maetche Wellness
• Katherine Whitney Maguire
• Main Street Family Services
• Chelsiedinnise Iya Malinao
• Skyler Lyn Manka
• Skylar R Marsolek
• Dylan Martin
• Kaylie Ann Martin
• Rebecca Marie Martin, RN

• Psychiatric/Mental Health Nurse Practitioner in Elk River, MN
• Providers in Elk River, MN by specialty
• Psychiatric/Mental Health Nurse Practitioner in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 15, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.