Healthcare Provider Details

I. General information

NPI: 1497525679
Provider Name (Legal Business Name): MAYSAH EHEALTH & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N HAMMES AVE STE 300B
JOLIET IL
60435-7661
US

IV. Provider business mailing address

21349 WESTMINSTER LN
SHOREWOOD IL
60404-2501
US

V. Phone/Fax

Practice location:
  • Phone: 815-714-9933
  • Fax: 949-695-3321
Mailing address:
  • Phone: 815-714-9933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MUTENGWANA KASAPU-MWABA
Title or Position: OWNER
Credential: FNP
Phone: 678-559-5065