Provider Demographics
NPI:1891501078
Name:MBEBI, MELODIE LAFORTUNE
Entity type:Individual
Prefix:
First Name:MELODIE
Middle Name:LAFORTUNE
Last Name:MBEBI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 CLOVERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-5368
Mailing Address - Country:US
Mailing Address - Phone:301-825-4905
Mailing Address - Fax:
Practice Address - Street 1:8000 CLOVERWOOD CT
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-5368
Practice Address - Country:US
Practice Address - Phone:301-825-4905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDF10240857363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty