Provider Demographics
NPI:1386107035
Name:NKEGOA, ELVIS
Entity type:Individual
Prefix:
First Name:ELVIS
Middle Name:
Last Name:NKEGOA
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 1:6002 CAMILLO CT
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-3522
Mailing Address - Country:US
Mailing Address - Phone:240-614-9704
Mailing Address - Fax:
Practice Address - Street 1:6002 CAMILLO CT
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-3522
Practice Address - Country:US
Practice Address - Phone:240-614-9704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14373251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health