Healthcare Provider Details

I. General information

NPI: 1023725728
Provider Name (Legal Business Name): HILDA MKWEZALAMBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 CHICKORY DR
CHAMPAIGN IL
61822-2101
US

IV. Provider business mailing address

810 CHICKORY DR
CHAMPAIGN IL
61822-2101
US

V. Phone/Fax

Practice location:
  • Phone: 217-819-0573
  • Fax: 443-312-5613
Mailing address:
  • Phone: 217-819-0573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0400X
TaxonomyRehabilitation Registered Nurse
License Number041400061
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: