Provider Demographics
NPI:1346990850
Name:MAMBOWENINGA, ESTHER
Entity Type:Individual
Prefix:
First Name:ESTHER
Middle Name:
Last Name:MAMBOWENINGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ESTHER
Other - Middle Name:
Other - Last Name:MUPINDU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10261 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-2015
Mailing Address - Country:US
Mailing Address - Phone:228-238-6779
Mailing Address - Fax:
Practice Address - Street 1:10261 LAKE FOREST DR
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565-2015
Practice Address - Country:US
Practice Address - Phone:228-238-6779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-27
Last Update Date:2022-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA5193225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant