MEDICARE: LIDWINA BOHMBED FONMBOH

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	163WH0200X	Home Health Registered Nurse	12971	DC
2	374U00000X	Home Health Aide	HHA12971	DC

General Provider Information

NPI Number	:	1285144790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIDWINA BOHMBED FONMBOH

Provider Business Mailing Address
First Line	:	6838 RIVERDALE RD APT 101
Second Line	:
City	:	LANHAM
State	:	MD
Zip	:	20706-1046
Country	:	US
Telephone Number	:	240-423-7155
Fax Number	:

Provider Business Practice Location Address
First Line	:	6838 RIVERDALE RD APT 101
Second Line	:
City	:	LANHAM
State	:	MD
Zip	:	20706-1046
Country	:	US
Telephone Number	:	240-423-7155
Fax Number	:

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

Provider Enumeration Date	:	10/10/2017
Last Update Date	:	11/01/2017

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