MEDICARE: UNKNOWN NKENGAFAC FUALEFAC FONGE

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	171M00000X	Case Manager/Care Coordinator		DC

General Provider Information

NPI Number	:	1326765991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	UNKNOWN NKENGAFAC FUALEFAC FONGE

Provider Business Mailing Address
First Line	:	9932 PRINCE ROYAL PL
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20774-1153
Country	:	US
Telephone Number	:	484-542-2588
Fax Number	:

Provider Business Practice Location Address
First Line	:	9932 PRINCE ROYAL PL
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20774-1153
Country	:	US
Telephone Number	:	484-542-2588
Fax Number	:

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

Provider Enumeration Date	:	10/25/2022
Last Update Date	:	10/07/2025

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