Provider Demographics
NPI:1104582204
Name:AZAAH, CLOVIS FONTEBO
Entity type:Individual
Prefix:
First Name:CLOVIS FONTEBO
Middle Name:
Last Name:AZAAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6823A RIVERDALE RD APT A2
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-1838
Mailing Address - Country:US
Mailing Address - Phone:240-487-8425
Mailing Address - Fax:
Practice Address - Street 1:6823A RIVERDALE RD APT A2
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1838
Practice Address - Country:US
Practice Address - Phone:240-487-8425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide