Healthcare Provider Details

I. General information

NPI: 1124951025
Provider Name (Legal Business Name): KISOB SALLY BINGWELAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9511 SHERIDAN ST
LANHAM MD
20706-2635
US

IV. Provider business mailing address

9511 SHERIDAN ST
LANHAM MD
20706-2635
US

V. Phone/Fax

Practice location:
  • Phone: 210-780-1803
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: