Healthcare Provider Details

I. General information

NPI: 1770146789
Provider Name (Legal Business Name): CONCILIA DABA ENJEH MARY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5309 RIVERDALE RD APT 402
RIVERDALE MD
20737-2232
US

IV. Provider business mailing address

5309 RIVERDALE RD APT 402
RIVERDALE MD
20737-2232
US

V. Phone/Fax

Practice location:
  • Phone: 240-495-4908
  • Fax:
Mailing address:
  • Phone: 301-792-0783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA14380
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: