Provider Demographics
NPI:1518413699
Name:ATABONG, SIDOLINE NKEGOU
Entity Type:Individual
Prefix:
First Name:SIDOLINE
Middle Name:NKEGOU
Last Name:ATABONG
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 1:6127 64TH AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-2936
Mailing Address - Country:US
Mailing Address - Phone:240-714-1802
Mailing Address - Fax:
Practice Address - Street 1:6127 64TH AVE APT 5
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-2936
Practice Address - Country:US
Practice Address - Phone:240-714-1802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12316374U00000X
251S00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide
No251S00000XAgenciesCommunity/Behavioral Health