Healthcare Provider Details

I. General information

NPI: 1780106559
Provider Name (Legal Business Name): LILIAN KAGENDO MWANGI FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E DAY RD
MISHAWAKA IN
46545-3471
US

IV. Provider business mailing address

57443 CABRIOLET CT
ELKHART IN
46516-8966
US

V. Phone/Fax

Practice location:
  • Phone: 574-247-8700
  • Fax:
Mailing address:
  • Phone: 574-322-0857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71007263A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: