Provider Demographics
NPI:1528575248
Name:RUSIBAMAYILA, OSWARLD NIYIDUHA IRAKUNDA
Entity Type:Individual
Prefix:
First Name:OSWARLD
Middle Name:NIYIDUHA IRAKUNDA
Last Name:RUSIBAMAYILA
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 1:7345 WOODLAND DR STE D
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1737
Mailing Address - Country:US
Mailing Address - Phone:317-286-2885
Mailing Address - Fax:317-536-3097
Practice Address - Street 1:1500 W NORTHMOOR RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-3435
Practice Address - Country:US
Practice Address - Phone:309-691-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX893242163W00000X
GARN273461163W00000X
IL041405733163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse