Provider Demographics
NPI:1467054064
Name:AMBELE, CONSTANCE IJANG
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:IJANG
Last Name:AMBELE
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 1:10111 MARGUERITA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-7502
Mailing Address - Country:US
Mailing Address - Phone:240-435-9709
Mailing Address - Fax:
Practice Address - Street 1:9507 LIVINGSTON RD
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-4919
Practice Address - Country:US
Practice Address - Phone:301-248-1333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26134183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist