Provider Demographics
NPI:1093690257
Name:KABANGU, MANNIX KALALA (SA-C)
Entity type:Individual
Prefix:
First Name:MANNIX
Middle Name:KALALA
Last Name:KABANGU
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16816 116TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-9119
Mailing Address - Country:US
Mailing Address - Phone:206-510-7233
Mailing Address - Fax:
Practice Address - Street 1:16816 116TH AVENUE CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-9119
Practice Address - Country:US
Practice Address - Phone:206-510-7233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-07
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
25-131246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant