Healthcare Provider Details

I. General information

NPI: 1447514187
Provider Name (Legal Business Name): DANIEL NDAMUKONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12008 CASTLE PINES LN
WALDORF MD
20602-3183
US

IV. Provider business mailing address

1731 BUNKER HILL RD NE
WASHINGTON DC
20017-3026
US

V. Phone/Fax

Practice location:
  • Phone: 202-258-5671
  • Fax: 240-607-6760
Mailing address:
  • Phone: 202-635-6133
  • Fax: 202-635-5780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License NumberRN963469
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR149775
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: