Provider Demographics
NPI:1811750383
Name:BWALYA, KALUBA
Entity type:Individual
Prefix:
First Name:KALUBA
Middle Name:
Last Name:BWALYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 WABASH PL
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2671
Mailing Address - Country:US
Mailing Address - Phone:651-434-2229
Mailing Address - Fax:
Practice Address - Street 1:491 WABASH PL
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2671
Practice Address - Country:US
Practice Address - Phone:651-434-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO148509376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide