Provider Demographics
NPI:1851143135
Name:PUOMAAYE KONTA, MAURICE
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:
Last Name:PUOMAAYE KONTA
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 1:7220 S SOUTH SHORE DR APT 406
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-2751
Mailing Address - Country:US
Mailing Address - Phone:312-774-5315
Mailing Address - Fax:
Practice Address - Street 1:7220 S SOUTH SHORE DR APT 406
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-2751
Practice Address - Country:US
Practice Address - Phone:872-901-2057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041399052163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministratorGroup - Multi-Specialty