Provider Demographics
NPI:1619480696
Name:KASAPU-MWABA, MUTENGWANA
Entity type:Individual
Prefix:MRS
First Name:MUTENGWANA
Middle Name:
Last Name:KASAPU-MWABA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N HAMMES AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-8118
Mailing Address - Country:US
Mailing Address - Phone:815-714-9933
Mailing Address - Fax:815-869-8738
Practice Address - Street 1:2025 S CHICAGO ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60436-3172
Practice Address - Country:US
Practice Address - Phone:815-726-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277002697363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily