Healthcare Provider Details

I. General information

NPI: 1295668796
Provider Name (Legal Business Name): KIZITO LOTACHUKWU MBAEKWE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 NINE IRON DR
CHAMPIONS GATE FL
33896-8025
US

IV. Provider business mailing address

2033 SE LENNARD RD APT 209
PORT SAINT LUCIE FL
34952-4748
US

V. Phone/Fax

Practice location:
  • Phone: 561-633-6392
  • Fax:
Mailing address:
  • Phone: 561-633-6392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9589560
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: