Healthcare Provider Details

I. General information

NPI: 1063344430
Provider Name (Legal Business Name): IVOLINE BENAZEA NKOAMBONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6323 GEORGIA AVE NW STE 360
WASHINGTON DC
20011-1101
US

IV. Provider business mailing address

4360 WELSH LN APT 5
WOODBRIDGE VA
22193-5649
US

V. Phone/Fax

Practice location:
  • Phone: 202-621-8494
  • Fax:
Mailing address:
  • Phone: 202-621-8494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001344754
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: