Provider Demographics
NPI:1114416567
Name:AKUNJI, AMBOMATEH ADONISE SR
Entity Type:Individual
Prefix:
First Name:AMBOMATEH
Middle Name:ADONISE
Last Name:AKUNJI
Suffix:SR
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 1:7124 MEADOW GREEN TER
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-5814
Mailing Address - Country:US
Mailing Address - Phone:301-404-5523
Mailing Address - Fax:
Practice Address - Street 1:7124 MEADOW GREEN TER
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-5814
Practice Address - Country:US
Practice Address - Phone:301-404-5523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13478374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD11382321500Medicaid