Healthcare Provider Details

I. General information

NPI: 1093445223
Provider Name (Legal Business Name): GERALDINE MBONEFOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2022
Last Update Date: 06/11/2022
Certification Date: 06/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5417 KIMBERMERE CT
GLEN ALLEN VA
23060-9253
US

IV. Provider business mailing address

PO BOX 70564
RICHMOND VA
23255-0564
US

V. Phone/Fax

Practice location:
  • Phone: 804-308-3890
  • Fax:
Mailing address:
  • Phone: 804-308-3890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: