Provider Demographics
NPI:1992281703
Name:MAMBO, MARRIETTE EKINDE
Entity type:Individual
Prefix:
First Name:MARRIETTE
Middle Name:EKINDE
Last Name:MAMBO
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 1:10424 FLORAL DR
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-1226
Mailing Address - Country:US
Mailing Address - Phone:240-595-8717
Mailing Address - Fax:
Practice Address - Street 1:901 1ST ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-1403
Practice Address - Country:US
Practice Address - Phone:202-282-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-15
Last Update Date:2018-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHHA13809374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
48246459OtherKAISER PERMANENTE