Provider Demographics
NPI:1447780366
Name:MUKUM FONGANG, LIVET ECHICK
Entity Type:Individual
Prefix:
First Name:LIVET
Middle Name:ECHICK
Last Name:MUKUM FONGANG
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 1:4506 WOODGATE WAY
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-3449
Mailing Address - Country:US
Mailing Address - Phone:240-714-8332
Mailing Address - Fax:
Practice Address - Street 1:4506 WOODGATE WAY
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-3449
Practice Address - Country:US
Practice Address - Phone:240-714-8332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-13
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12593374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty