Healthcare Provider Details

I. General information

NPI: 1619770369
Provider Name (Legal Business Name): MUNACHISO AMANDA NGENE MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA MUNACHISO NGENE MD, MPH

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 W 95TH ST STE 210
OAK LAWN IL
60453-2793
US

IV. Provider business mailing address

4220 W 95TH ST STE 210
OAK LAWN IL
60453-2793
US

V. Phone/Fax

Practice location:
  • Phone: 312-949-4200
  • Fax: 708-423-1899
Mailing address:
  • Phone: 312-949-4200
  • Fax: 708-423-1899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125085341
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: