Provider Demographics
NPI:1720105612
Name:KAPUNO, OMEGA AMY T (PT)
Entity Type:Individual
Prefix:MS
First Name:OMEGA AMY
Middle Name:T
Last Name:KAPUNO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-326-2911
Mailing Address - Fax:217-344-8047
Practice Address - Street 1:1504 EAST GROVE
Practice Address - Street 2:
Practice Address - City:RANTOUL
Practice Address - State:IL
Practice Address - Zip Code:61866-2736
Practice Address - Country:US
Practice Address - Phone:217-893-7720
Practice Address - Fax:217-893-7803
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203OtherBLUE CROSS PROV ID
IL4117OtherHAMP PROV ID
7216OtherPERSONALCARE PROV ID
113326OtherHEALTHLINK PROV ID
140091Medicare ID - Type Unspecified