Provider Demographics
NPI:1992176127
Name:NGO NGUIDJOE BODOUM, ELISE NORA
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:NORA
Last Name:NGO NGUIDJOE BODOUM
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 1:5124 KENILWORTH AVE
Mailing Address - Street 2:APT 10
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20781-2539
Mailing Address - Country:US
Mailing Address - Phone:240-544-8783
Mailing Address - Fax:
Practice Address - Street 1:5124 KENILWORTH AVE
Practice Address - Street 2:APT 10
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20781-2539
Practice Address - Country:US
Practice Address - Phone:240-544-8783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA11533374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide