Provider Demographics
NPI:1528607405
Name:FANKEP DJOMO, MARIE GAILLE
Entity Type:Individual
Prefix:
First Name:MARIE GAILLE
Middle Name:
Last Name:FANKEP DJOMO
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 1:6735 NEW HAMPSHIRE AVE APT 913
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-2833
Mailing Address - Country:US
Mailing Address - Phone:240-758-1867
Mailing Address - Fax:
Practice Address - Street 1:6735 NEW HAMPSHIRE AVE APT 913
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-2833
Practice Address - Country:US
Practice Address - Phone:240-758-1867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-24
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14905374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty