Healthcare Provider Details

I. General information

NPI: 1194573816
Provider Name (Legal Business Name): BERTH MEFEUKAMGUA EPSE DJOK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 NALLEY RD APT 211
HYATTSVILLE MD
20785-4431
US

IV. Provider business mailing address

1121 NALLEY RD APT 211
HYATTSVILLE MD
20785-4431
US

V. Phone/Fax

Practice location:
  • Phone: 407-096-6002
  • Fax:
Mailing address:
  • Phone: 407-096-6002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA200003727
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: