Provider Demographics
NPI:1164786505
Name:AMBOMU, IFA
Entity Type:Individual
Prefix:
First Name:IFA
Middle Name:
Last Name:AMBOMU
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 1:4920 NIAGARA RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-1110
Mailing Address - Country:US
Mailing Address - Phone:301-982-6477
Mailing Address - Fax:301-982-6488
Practice Address - Street 1:4920 NIAGARA RD
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-1110
Practice Address - Country:US
Practice Address - Phone:301-982-6477
Practice Address - Fax:301-982-6488
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide