=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609334283
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAMMON MOLLOH-FORNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2019
-----------------------------------------------------
Last Update Date | 03/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2512 24TH ST NE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20018-2126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-832-8340
-----------------------------------------------------
Fax | 202-832-8341
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9789 GOOD LUCK RD APT 16
-----------------------------------------------------
City | LANHAM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20706-3343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-370-3881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | HHA14325
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------