Healthcare Provider Details

I. General information

NPI: 1770097503
Provider Name (Legal Business Name): LACKALONG NDIKUM NDIFOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8627 ANNAPOLIS RD
NEW CARROLLTON MD
20784-3108
US

IV. Provider business mailing address

8627 ANNAPOLIS RD
NEW CARROLLTON MD
20784-3108
US

V. Phone/Fax

Practice location:
  • Phone: 302-423-4568
  • Fax:
Mailing address:
  • Phone: 302-423-4568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA13240
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: