Provider Demographics
NPI:1174407027
Name:MABAMBA, KAYLA JEAN (PT)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:JEAN
Last Name:MABAMBA
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 1:8365 FAIRCHILD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55112-6122
Mailing Address - Country:US
Mailing Address - Phone:507-676-0463
Mailing Address - Fax:
Practice Address - Street 1:8365 FAIRCHILD AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55112-6122
Practice Address - Country:US
Practice Address - Phone:507-676-0463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11730225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist