Provider Demographics
NPI:1144578550
Name:FONGE, LISSETTE MUKE
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:MUKE
Last Name:FONGE
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 1:2306 BRIGHTSEAT RD APT 5
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-3550
Mailing Address - Country:US
Mailing Address - Phone:202-758-4209
Mailing Address - Fax:
Practice Address - Street 1:2306 BRIGHTSEAT RD APT 5
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-3550
Practice Address - Country:US
Practice Address - Phone:202-758-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide