Provider Demographics
NPI:1942028535
Name:KEBBIE, MBALU MADLENE
Entity type:Individual
Prefix:
First Name:MBALU
Middle Name:MADLENE
Last Name:KEBBIE
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 1:2111 LINCOLNSHIRE DR SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-1606
Mailing Address - Country:US
Mailing Address - Phone:319-533-4485
Mailing Address - Fax:
Practice Address - Street 1:2111 LINCOLNSHIRE DR SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-1606
Practice Address - Country:US
Practice Address - Phone:319-533-4485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG179854363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health