Provider Demographics
NPI:1194217760
Name:KAMBA, BRENT LUSAMBA-KASENDE (FNP-C)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:LUSAMBA-KASENDE
Last Name:KAMBA
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6013 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5220
Mailing Address - Country:US
Mailing Address - Phone:801-255-5131
Mailing Address - Fax:801-658-0604
Practice Address - Street 1:261 N ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-2617
Practice Address - Country:US
Practice Address - Phone:801-688-4952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2023-09-26
Deactivation Date:2023-09-15
Deactivation Code:
Reactivation Date:2023-09-26
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
AZ297664363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty