=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285179648
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER SSEMPAKA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2016
-----------------------------------------------------
Last Update Date | 12/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2111 WILLOW BROOKE DR APT 1A
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60098-5264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-654-3436
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2111 WILLOW BROOKE DR APT 1A
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60098-5264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-654-3463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 043118126
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------