Healthcare Provider Details

I. General information

NPI: 1992062624
Provider Name (Legal Business Name): NICOLAS GBEDEMAKOU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2642 12TH ST. NE
WAASHINGTON DC
20018
US

IV. Provider business mailing address

8208 MANDAN CT
GREENBELT MD
20770
US

V. Phone/Fax

Practice location:
  • Phone: 202-269-1619
  • Fax: 202-683-6739
Mailing address:
  • Phone: 202-269-1619
  • Fax: 202-683-6739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: