Healthcare Provider Details

I. General information

NPI: 1245693092
Provider Name (Legal Business Name): VALERY MBANWI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 POTOMAC CT
GLENN DALE MD
20769-1901
US

IV. Provider business mailing address

7500 POTOMAC CT
GLENN DALE MD
20769-1901
US

V. Phone/Fax

Practice location:
  • Phone: 240-713-7379
  • Fax:
Mailing address:
  • Phone: 240-713-7379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA11924
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberHHA11924
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: