Healthcare Provider Details

I. General information

NPI: 1013843002
Provider Name (Legal Business Name): BERNARD FOMBIN NKENGBEZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8601 GRAY FOX RD
RANDALLSTOWN MD
21133-5148
US

IV. Provider business mailing address

8601 GRAY FOX RD
RANDALLSTOWN MD
21133-5148
US

V. Phone/Fax

Practice location:
  • Phone: 443-334-7270
  • Fax:
Mailing address:
  • Phone: 443-334-7270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA200006629
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: