Healthcare Provider Details

I. General information

NPI: 1801154471
Provider Name (Legal Business Name): KEHBILA EVONCE BAYUGA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 09/28/2024
Certification Date: 09/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 GOOD HOPE RD SE
WASHINGTON DC
20020-5615
US

IV. Provider business mailing address

5021 TOWNSEND WAY APT C3
BLADENSBURG MD
20710-1880
US

V. Phone/Fax

Practice location:
  • Phone: 202-558-2448
  • Fax: 202-204-5758
Mailing address:
  • Phone: 240-330-3547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number1055857
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: