Provider Demographics
NPI:1497311104
Name:MALONGA, SYLVERE ROLAND
Entity Type:Individual
Prefix:MR
First Name:SYLVERE
Middle Name:ROLAND
Last Name:MALONGA
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 1:1475 BASSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-5419
Mailing Address - Country:US
Mailing Address - Phone:630-417-9417
Mailing Address - Fax:
Practice Address - Street 1:1475 BASSWOOD DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-5419
Practice Address - Country:US
Practice Address - Phone:630-417-9417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.301622163W00000X
IL209.017752363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse