Healthcare Provider Details

I. General information

NPI: 1770930281
Provider Name (Legal Business Name): YANICK EYONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 KINGS TREE DR
BOWIE MD
20721-1918
US

IV. Provider business mailing address

1031 KINGS TREE DR
BOWIE MD
20721-1918
US

V. Phone/Fax

Practice location:
  • Phone: 240-280-4133
  • Fax:
Mailing address:
  • Phone: 240-280-4133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA12069
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: