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General NPI Number Information
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NPI Number | 1588333033
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Entity Type | Individual
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Provider Name | MUBANGU MADO MANDAMUNA
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Gender | Female
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Dates
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Enumeration Date | 09/08/2021
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Last Update Date | 12/29/2022
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Provider Practice Location Address
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Address Line | 201 N RANDOLPH ST
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City | CHAMPAIGN
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State | IL
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Zip | 61820-3935
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Country | US
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Telephone | 877-726-6494
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Fax |
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Provider Business Mailing Address
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Address Line | 3723 SUMMER SAGE CT
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City | CHAMPAIGN
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State | IL
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Zip | 61822-1907
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QH0002X
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Taxonomy Name | Hospice and Palliative Medicine (Family Medicine) Physician
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License Number | 209023791
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209023791
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License Number State | IL
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