Provider Demographics
NPI:1316564206
Name:KYOMO, JILLY
Entity Type:Individual
Prefix:
First Name:JILLY
Middle Name:
Last Name:KYOMO
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 1:14115 PORRINGER CT
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-2062
Mailing Address - Country:US
Mailing Address - Phone:301-383-7406
Mailing Address - Fax:
Practice Address - Street 1:14115 PORRINGER CT
Practice Address - Street 2:
Practice Address - City:BURTONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20866-2062
Practice Address - Country:US
Practice Address - Phone:301-383-7406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMTO139237146N00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDMTO139237Medicaid