Provider Demographics
NPI:1366969610
Name:MOKUA, LILIAN
Entity type:Individual
Prefix:
First Name:LILIAN
Middle Name:
Last Name:MOKUA
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 1:1121 DARNABY WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-5035
Mailing Address - Country:US
Mailing Address - Phone:321-217-9058
Mailing Address - Fax:
Practice Address - Street 1:625 FLORIDA PKWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34743-7548
Practice Address - Country:US
Practice Address - Phone:321-217-9058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376G00000X
FL12963310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No376G00000XNursing Service Related ProvidersNursing Home Administrator