Provider Demographics
NPI:1376095778
Name:MIREILLE, NKWENTI
Entity Type:Individual
Prefix:
First Name:NKWENTI
Middle Name:
Last Name:MIREILLE
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 1:14921 DENNINGTON DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3273
Mailing Address - Country:US
Mailing Address - Phone:240-486-8639
Mailing Address - Fax:
Practice Address - Street 1:14921 DENNINGTON DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20721-3273
Practice Address - Country:US
Practice Address - Phone:240-486-8639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12530374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide