Provider Demographics
NPI:1841806916
Name:WAMBUGU, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:WAMBUGU
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 1:2812 ROYALLVALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-6989
Mailing Address - Country:US
Mailing Address - Phone:314-441-0103
Mailing Address - Fax:
Practice Address - Street 1:1251 N STATE ST
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-1169
Practice Address - Country:US
Practice Address - Phone:618-498-6441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.003928225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist