Healthcare Provider Details

I. General information

NPI: 1629668157
Provider Name (Legal Business Name): CALVIN NKENGASONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6215 FERNWOOD TER # TERRACE2
RIVERDALE MD
20737-1637
US

IV. Provider business mailing address

6215 FERNWOOD TER # TERRACE2
RIVERDALE MD
20737-1637
US

V. Phone/Fax

Practice location:
  • Phone: 240-422-4579
  • Fax:
Mailing address:
  • Phone: 240-422-4579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA15651
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: