Provider Demographics
NPI:1336968700
Name:DEFANG FONDONG, BRONDEL
Entity type:Individual
Prefix:
First Name:BRONDEL
Middle Name:
Last Name:DEFANG FONDONG
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 1:6275 64TH AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-2960
Mailing Address - Country:US
Mailing Address - Phone:240-704-1596
Mailing Address - Fax:
Practice Address - Street 1:6275 64TH AVE APT 1
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-2960
Practice Address - Country:US
Practice Address - Phone:240-704-1596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker