Provider Demographics
NPI:1134482078
Name:KONCHOU, IDA MABELLE (HHA)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:MABELLE
Last Name:KONCHOU
Suffix:
Gender:F
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6731 NEW HAMPSHIRE AVE APT 409
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-2801
Mailing Address - Country:US
Mailing Address - Phone:202-545-0935
Mailing Address - Fax:202-545-0934
Practice Address - Street 1:6731 NEW HAMPSHIRE AVE APT 409
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-2801
Practice Address - Country:US
Practice Address - Phone:202-545-0935
Practice Address - Fax:202-545-0934
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR207705363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health