Healthcare Provider Details

I. General information

NPI: 1558856476
Provider Name (Legal Business Name): ROSINE KELLY KOUEBOU MBOUKEM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 06/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 SOUTHAMPTON DR
SILVER SPRING MD
20903-2633
US

IV. Provider business mailing address

528 SOUTHAMPTON DR
SILVER SPRING MD
20903-2633
US

V. Phone/Fax

Practice location:
  • Phone: 240-645-8318
  • Fax:
Mailing address:
  • Phone: 240-645-8318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA13767
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: