MEDICARE: DONNY MUKUM TEBONG

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	376K00000X	Nurse's Aide	100953	MD

General Provider Information

NPI Number	:	1881320539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNY MUKUM TEBONG

Provider Business Mailing Address
First Line	:	3409 DODGE PARK RD
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-2021
Country	:	US
Telephone Number	:	240-467-6106
Fax Number	:	410-946-2109

Provider Business Practice Location Address
First Line	:	3409 DODGE PARK RD
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-2021
Country	:	US
Telephone Number	:	240-467-6106
Fax Number	:	410-946-2109

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

Provider Enumeration Date	:	07/26/2022
Last Update Date	:	07/26/2022

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