Provider Demographics
NPI:1376299719
Name:MATANDA, NELLY ILUNGA
Entity Type:Individual
Prefix:
First Name:NELLY
Middle Name:ILUNGA
Last Name:MATANDA
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 1:95 WEIR DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:ND
Mailing Address - Zip Code:58504-9199
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:95 WEIR DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ND
Practice Address - Zip Code:58504-9199
Practice Address - Country:US
Practice Address - Phone:217-904-0375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant