Provider Demographics
NPI:1376948034
Name:NWAMBA, CALLISTUS NWABUEZE
Entity Type:Individual
Prefix:
First Name:CALLISTUS
Middle Name:NWABUEZE
Last Name:NWAMBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2799 NOTTINGHILL ROW
Mailing Address - Street 2:APT J
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-2409
Mailing Address - Country:US
Mailing Address - Phone:314-536-0149
Mailing Address - Fax:
Practice Address - Street 1:2799 NOTTINGHILL ROW
Practice Address - Street 2:APT J
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-2409
Practice Address - Country:US
Practice Address - Phone:314-536-0149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO129861376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO9113902602OtherUMR