Healthcare Provider Details

I. General information

NPI: 1821544818
Provider Name (Legal Business Name): MR. KELLIE FAGBOWA MARAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 WISCONSIN AVE NW
WASHINGTON DC
20007-3603
US

IV. Provider business mailing address

6529 LANDOVER RD APT 102
CHEVERLY MD
20785-1429
US

V. Phone/Fax

Practice location:
  • Phone: 202-955-8355
  • Fax: 703-753-8793
Mailing address:
  • Phone: 240-706-1658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1028482
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN1028482
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberR203641
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: