Provider Demographics
NPI:1225556491
Name:MBALALE, KEVINE DJUIMTSOP
Entity Type:Individual
Prefix:
First Name:KEVINE
Middle Name:DJUIMTSOP
Last Name:MBALALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEVINE
Other - Middle Name:D
Other - Last Name:MBALALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1223 QUINCY ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-5768
Mailing Address - Country:US
Mailing Address - Phone:240-821-3421
Mailing Address - Fax:
Practice Address - Street 1:2010 RHODE ISLAND AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2835
Practice Address - Country:US
Practice Address - Phone:240-616-8092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC13056374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide