Provider Demographics
NPI:1144796517
Name:MUKUM, BRANDON V
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:V
Last Name:MUKUM
Suffix:
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 1:3115 QUEENS CHAPEL RD # 3
Mailing Address - Street 2:
Mailing Address - City:MOUNT RAINIER
Mailing Address - State:MD
Mailing Address - Zip Code:20712-1157
Mailing Address - Country:US
Mailing Address - Phone:202-855-4826
Mailing Address - Fax:
Practice Address - Street 1:3115 QUEENS CHAPEL RD # 3
Practice Address - Street 2:
Practice Address - City:MOUNT RAINIER
Practice Address - State:MD
Practice Address - Zip Code:20712-1157
Practice Address - Country:US
Practice Address - Phone:202-855-4826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDHHA13995374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide