Provider Demographics
NPI:1104400837
Name:KATAMBWA, ILUNGA (NP)
Entity Type:Individual
Prefix:
First Name:ILUNGA
Middle Name:
Last Name:KATAMBWA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 LUNENBURG DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-8166
Mailing Address - Country:US
Mailing Address - Phone:314-922-1822
Mailing Address - Fax:
Practice Address - Street 1:1621 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63102-1299
Practice Address - Country:US
Practice Address - Phone:314-922-1822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023035006363LP0808X
MO2021016520363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily