Provider Demographics
NPI:1205418902
Name:MBALLA, MELANIE MENGUE
Entity Type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:MENGUE
Last Name:MBALLA
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 1:9502 WASHINGTON BLVD # 20706
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-4031
Mailing Address - Country:US
Mailing Address - Phone:301-256-6774
Mailing Address - Fax:
Practice Address - Street 1:9502 WASHINGTON BLVD APT 202
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-4031
Practice Address - Country:US
Practice Address - Phone:301-256-6774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide