Provider Demographics
NPI:1003457631
Name:MWAMBO, BLANDINE MONJOWA EMMANUELLA
Entity Type:Individual
Prefix:
First Name:BLANDINE
Middle Name:MONJOWA EMMANUELLA
Last Name:MWAMBO
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 1:3422 DODGE PARK RD APT 203
Mailing Address - Street 2:
Mailing Address - City:LANDOVER
Mailing Address - State:MD
Mailing Address - Zip Code:20785-2047
Mailing Address - Country:US
Mailing Address - Phone:240-899-4436
Mailing Address - Fax:
Practice Address - Street 1:7826 EASTERN AVE NW STE LL16
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1328
Practice Address - Country:US
Practice Address - Phone:202-723-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14672374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide