Healthcare Provider Details

I. General information

NPI: 1063223782
Provider Name (Legal Business Name): BLAISE AWAMBENG FRU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7406 VANDENBERG CT
LANHAM MD
20706-3374
US

IV. Provider business mailing address

7406 VANDENBERG CT
LANHAM MD
20706-3374
US

V. Phone/Fax

Practice location:
  • Phone: 540-277-4873
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: