Provider Demographics
NPI:1316485907
Name:MAWAMBA KEUBOU, MICAILLE FLORE
Entity type:Individual
Prefix:
First Name:MICAILLE FLORE
Middle Name:
Last Name:MAWAMBA KEUBOU
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 1:6811 RIGGS MANOR DR
Mailing Address - Street 2:APT 302
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-2943
Mailing Address - Country:US
Mailing Address - Phone:240-470-9158
Mailing Address - Fax:
Practice Address - Street 1:6811 RIGGS MANOR DR
Practice Address - Street 2:APT 302
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-2943
Practice Address - Country:US
Practice Address - Phone:240-470-9158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide