Provider Demographics
NPI:1699502237
Name:KIEGUING KOUAM, EMMANUEL RENE
Entity type:Individual
Prefix:
First Name:EMMANUEL RENE
Middle Name:
Last Name:KIEGUING KOUAM
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 1:3534 CASTLE HILL DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-5324
Mailing Address - Country:US
Mailing Address - Phone:202-867-3789
Mailing Address - Fax:
Practice Address - Street 1:702 15TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4508
Practice Address - Country:US
Practice Address - Phone:202-867-3789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker