Provider Demographics
NPI:1316336977
Name:AFOR FONGYEN, MISPA
Entity type:Individual
Prefix:
First Name:MISPA
Middle Name:
Last Name:AFOR FONGYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISPA
Other - Middle Name:
Other - Last Name:OMOJUWA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3801 KENILWORTH AVE APT 409W
Mailing Address - Street 2:
Mailing Address - City:BLADENSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20710-2138
Mailing Address - Country:US
Mailing Address - Phone:301-458-9152
Mailing Address - Fax:
Practice Address - Street 1:8012 CRADDOCK RD
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3050
Practice Address - Country:US
Practice Address - Phone:240-854-0908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA11010374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide