Provider Demographics
NPI:1699263244
Name:MBITEGHAMBO, MBAH HENRY
Entity type:Individual
Prefix:
First Name:MBAH
Middle Name:HENRY
Last Name:MBITEGHAMBO
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 1:3215 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-1923
Mailing Address - Country:US
Mailing Address - Phone:443-565-2156
Mailing Address - Fax:
Practice Address - Street 1:3215 75TH AVE
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-1923
Practice Address - Country:US
Practice Address - Phone:443-565-2156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13614374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide