Provider Demographics
NPI:1699539833
Name:BERTRAND, FONACHU NUBEDWOE
Entity type:Individual
Prefix:
First Name:FONACHU
Middle Name:NUBEDWOE
Last Name:BERTRAND
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 1:6320 BRIGHTLEA DR
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2866
Mailing Address - Country:US
Mailing Address - Phone:240-429-1046
Mailing Address - Fax:
Practice Address - Street 1:6320 BRIGHTLEA DR
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-2866
Practice Address - Country:US
Practice Address - Phone:240-429-1046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171M00000X
171M00000X
DC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty