Healthcare Provider Details

I. General information

NPI: 1083972822
Provider Name (Legal Business Name): JENET ENGONWEI MBAH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3267 QUEENSTOWN DR 301
MOUNT RAINIER MD
20712-1080
US

IV. Provider business mailing address

3267 QUEENSTOWN DR 301
MOUNT RAINIER MD
20712-1080
US

V. Phone/Fax

Practice location:
  • Phone: 240-476-1036
  • Fax:
Mailing address:
  • Phone: 240-476-1036
  • 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: