Provider Demographics
NPI:1265021885
Name:EGBUFOAMA, KENNETH CHUCKS
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:CHUCKS
Last Name:EGBUFOAMA
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 1:6323 GEORGIA AVE NW STE 305
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-1141
Mailing Address - Country:US
Mailing Address - Phone:202-506-1242
Mailing Address - Fax:202-506-1396
Practice Address - Street 1:6323 GEORGIA AVE NW STE 305
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1141
Practice Address - Country:US
Practice Address - Phone:202-506-1242
Practice Address - Fax:202-506-1396
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANA0000812544376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide