MEDICARE: CHANTAL KOUAMOU WANDJI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide	HHA12663	DC

General Provider Information

NPI Number	:	1306376207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANTAL KOUAMOU WANDJI

Provider Business Mailing Address
First Line	:	8617 ANNAPOLIS RD APT 2
Second Line	:
City	:	NEW CARROLLTON
State	:	MD
Zip	:	20784-3103
Country	:	US
Telephone Number	:	410-565-2988
Fax Number	:

Provider Business Practice Location Address
First Line	:	8617 ANNAPOLIS RD APT 2
Second Line	:
City	:	NEW CARROLLTON
State	:	MD
Zip	:	20784-3103
Country	:	US
Telephone Number	:	410-565-2988
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2017
Last Update Date	:	06/14/2017

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