Healthcare Provider Details

I. General information

NPI: 1780483651
Provider Name (Legal Business Name): ERIC MBAH NKWENTI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 ESSENTON DR
UPPER MARLBORO MD
20774-1812
US

IV. Provider business mailing address

116 ESSENTON DR
UPPER MARLBORO MD
20774-1812
US

V. Phone/Fax

Practice location:
  • Phone: 240-304-5108
  • Fax:
Mailing address:
  • Phone: 240-304-5108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: