Provider Demographics
NPI:1114438470
Name:MBONG EWANE, EDITH EBUDETUBE SR
Entity Type:Individual
Prefix:MS
First Name:EDITH
Middle Name:EBUDETUBE
Last Name:MBONG EWANE
Suffix:SR
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 1:13503 AVEBURY DR APT 23
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-3432
Mailing Address - Country:US
Mailing Address - Phone:703-870-5375
Mailing Address - Fax:
Practice Address - Street 1:2512 24TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2126
Practice Address - Country:US
Practice Address - Phone:703-870-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13148374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide