Healthcare Provider Details

I. General information

NPI: 1912416538
Provider Name (Legal Business Name): MRS. VANESSA EWONGO NAMME
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date: 03/26/2023
Reactivation Date: 03/30/2023

III. Provider practice location address

7741 RIVERDALE RD
NEW CARROLLTON MD
20784-3911
US

IV. Provider business mailing address

7741 RIVERDALE RD
NEW CARROLLTON MD
20784-3911
US

V. Phone/Fax

Practice location:
  • Phone: 240-746-8936
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA13110
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: