MEDICARE: AZOMBUH YANICK AWUNGAFAC

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

General Provider Information

NPI Number	:	1942988910
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AZOMBUH YANICK AWUNGAFAC

Provider Business Mailing Address
First Line	:	13302 BLACK DUCK CT
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20774-7011
Country	:	US
Telephone Number	:	424-535-6255
Fax Number	:

Provider Business Practice Location Address
First Line	:	2811 PENNSYLVANIA AVE SE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20020-3865
Country	:	US
Telephone Number	:	202-894-6811
Fax Number	:

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

Provider Enumeration Date	:	07/10/2023
Last Update Date	:	07/10/2023

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