=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770308546
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BINE NNOKO MBOH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2024
-----------------------------------------------------
Last Update Date | 11/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 702 15TH ST NE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20002-4508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-388-8500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12904 NORTHAMPTON DR
-----------------------------------------------------
City | BELTSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20705-6332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-754-4428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------