MEDICARE: THEODELLA ENDAM MBAH

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		DC

General Provider Information

NPI Number	:	1770441495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEODELLA ENDAM MBAH

Provider Business Mailing Address
First Line	:	6827C RIVERDALE RD APT C201
Second Line	:
City	:	RIVERDALE
State	:	MD
Zip	:	20737-3857
Country	:	US
Telephone Number	:	771-233-9302
Fax Number	:

Provider Business Practice Location Address
First Line	:	6827C RIVERDALE RD APT C201
Second Line	:
City	:	RIVERDALE
State	:	MD
Zip	:	20737-3857
Country	:	US
Telephone Number	:	771-233-9302
Fax Number	:

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

Provider Enumeration Date	:	01/12/2026
Last Update Date	:	01/12/2026

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