Provider Demographics
NPI:1356824890
Name:BANGURA, ELIZABETH BONGHOR
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:BONGHOR
Last Name:BANGURA
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 1:3108 PS BUSINESS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4258
Mailing Address - Country:US
Mailing Address - Phone:571-552-3509
Mailing Address - Fax:
Practice Address - Street 1:1940 GABLERIDGE TURN
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-1972
Practice Address - Country:US
Practice Address - Phone:703-899-9642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00165718374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide