MEDICARE: ODETTE NGUM FOMINYAM

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	251S00000X	Community/Behavioral Health Agency
2	374U00000X	Home Health Aide	HHA14118	DC
3	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1750851234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ODETTE NGUM FOMINYAM

Provider Business Mailing Address
First Line	:	4806 WILLES VISION DR
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20720-4671
Country	:	US
Telephone Number	:	240-616-8239
Fax Number	:

Provider Business Practice Location Address
First Line	:	4806 WILLES VISION DR
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20720-4671
Country	:	US
Telephone Number	:	240-616-8239
Fax Number	:

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

Provider Enumeration Date	:	11/28/2018
Last Update Date	:	07/25/2023

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