MEDICARE: JOSEPH ENONGENE MBONG BSN, RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	R218959	MD

General Provider Information

NPI Number	:	1144819806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH ENONGENE MBONG BSN, RN

Provider Business Mailing Address
First Line	:	605 RED CT
Second Line	:
City	:	FREDERICK
State	:	MD
Zip	:	21703-2243
Country	:	US
Telephone Number	:	240-421-4702
Fax Number	:

Provider Business Practice Location Address
First Line	:	4101 OLD NATIONAL PIKE
Second Line	:
City	:	MOUNT AIRY
State	:	MD
Zip	:	21771-4115
Country	:	US
Telephone Number	:	301-829-0800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2021
Last Update Date	:	01/15/2021

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