Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 2015011346 | MO |
NPI | 1003115536 |
---|---|
Provider Name | Mrs. Gladys Grace Tiwonge Kamanga-Sollo |
First Address | Cape Girardeau, MO 63701-4566 |
Second Address | Cape Girardeau, MO 63701-4566 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/03/2011 |
Last Update Date | 14/07/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2015011346 | MO STATE LICENSE (01) | MO |