MEDICARE: MRS. ANGE WENDYAM GANSORE

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	HHA13644	DC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HHA13644	OTHER	DC	GOVERNMENT OF THE DISTRICT OF COLUMBIA

General Provider Information

NPI Number	:	1841789187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANGE WENDYAM GANSORE

Provider Business Mailing Address
First Line	:	11215 OAK LEAF DR APT 120
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20901-1364
Country	:	US
Telephone Number	:	304-918-8805
Fax Number	:

Provider Business Practice Location Address
First Line	:	11215 OAK LEAF DR APT 120
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20901-1364
Country	:	US
Telephone Number	:	304-918-8805
Fax Number	:

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

Provider Enumeration Date	:	05/02/2018
Last Update Date	:	05/02/2018

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