Provider Demographics
NPI:1285144790
Name:FONMBOH, LIDWINA BOHMBED
Entity type:Individual
Prefix:
First Name:LIDWINA
Middle Name:BOHMBED
Last Name:FONMBOH
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 1:6838 RIVERDALE RD APT 101
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-1046
Mailing Address - Country:US
Mailing Address - Phone:240-423-7155
Mailing Address - Fax:
Practice Address - Street 1:6838 RIVERDALE RD APT 101
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-1046
Practice Address - Country:US
Practice Address - Phone:240-423-7155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC12971163WH0200X
DCHHA12971374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No163WH0200XNursing Service ProvidersRegistered NurseHome Health