Healthcare Provider Details

I. General information

NPI: 1275123911
Provider Name (Legal Business Name): ISATA BANGURA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5504 GLEN AVE
LANHAM MD
20706-4718
US

IV. Provider business mailing address

5504 GLEN AVE
LANHAM MD
20706-4718
US

V. Phone/Fax

Practice location:
  • Phone: 202-588-8036
  • Fax:
Mailing address:
  • Phone: 240-505-0208
  • Fax: 410-946-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberA00185391
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: