Provider Demographics
NPI:1588859169
Name:MAFAZY, MUNIB SAID (NURSE PRACTIONER)
Entity Type:Individual
Prefix:MR
First Name:MUNIB
Middle Name:SAID
Last Name:MAFAZY
Suffix:
Gender:M
Credentials:NURSE PRACTIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3566
Mailing Address - Country:US
Mailing Address - Phone:309-661-6900
Mailing Address - Fax:
Practice Address - Street 1:2204 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3566
Practice Address - Country:US
Practice Address - Phone:309-661-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.006784363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily