Provider Demographics
NPI:1598261133
Name:BOUGEKA, LARISSA JUNIL KEMGNE
Entity Type:Individual
Prefix:
First Name:LARISSA JUNIL
Middle Name:KEMGNE
Last Name:BOUGEKA
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 1:1912 FOX ST APT 104
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-2362
Mailing Address - Country:US
Mailing Address - Phone:240-224-1359
Mailing Address - Fax:
Practice Address - Street 1:1912 FOX ST APT 104
Practice Address - Street 2:
Practice Address - City:ADELPHI
Practice Address - State:MD
Practice Address - Zip Code:20783-2362
Practice Address - Country:US
Practice Address - Phone:240-224-1359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13192374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCHHA13192Medicaid