Provider Demographics
NPI:1154013159
Name:KOOMSON, ENOCK
Entity type:Individual
Prefix:
First Name:ENOCK
Middle Name:
Last Name:KOOMSON
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 1:16931 TOMS RIVER LOOP
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22026-2178
Mailing Address - Country:US
Mailing Address - Phone:571-357-9158
Mailing Address - Fax:
Practice Address - Street 1:16931 TOMS RIVER LOOP
Practice Address - Street 2:
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22026-2178
Practice Address - Country:US
Practice Address - Phone:240-825-7419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHC0-232911163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health