Provider Demographics
NPI:1154929305
Name:FORMUKONG, ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:FORMUKONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 MISSISSIPPI AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-4431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2759 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-2646
Practice Address - Country:US
Practice Address - Phone:202-827-9961
Practice Address - Fax:202-827-9963
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-10
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC70931318Medicaid