Provider Demographics
NPI:1518720424
Name:NGWA VEMOMBIH, RAISSA RELLA
Entity Type:Individual
Prefix:
First Name:RAISSA RELLA
Middle Name:
Last Name:NGWA VEMOMBIH
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 1:4410 POTOMAC HIGHLANDS CIR
Mailing Address - Street 2:
Mailing Address - City:TRIANGLE
Mailing Address - State:VA
Mailing Address - Zip Code:22172-1789
Mailing Address - Country:US
Mailing Address - Phone:703-884-6202
Mailing Address - Fax:
Practice Address - Street 1:4410 POTOMAC HIGHLANDS CIR
Practice Address - Street 2:
Practice Address - City:TRIANGLE
Practice Address - State:VA
Practice Address - Zip Code:22172-1789
Practice Address - Country:US
Practice Address - Phone:703-884-6202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA8073251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services