Healthcare Provider Details

I. General information

NPI: 1134893266
Provider Name (Legal Business Name): ELISE LOVELINE DJUNKEP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3922 BLACKBURN LN APT 13
BURTONSVILLE MD
20866-1265
US

IV. Provider business mailing address

3922 BLACKBURN LN APT 13
BURTONSVILLE MD
20866-1265
US

V. Phone/Fax

Practice location:
  • Phone: 917-774-1381
  • Fax:
Mailing address:
  • Phone: 917-774-1381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberA00166533
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: