Provider Demographics
NPI:1609139096
Name:ASONGWE, ANIMBENG
Entity Type:Individual
Prefix:
First Name:ANIMBENG
Middle Name:
Last Name:ASONGWE
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 1:6421 GWINNETT LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-5320
Mailing Address - Country:US
Mailing Address - Phone:301-357-3016
Mailing Address - Fax:
Practice Address - Street 1:17505 MADRILLON WAY
Practice Address - Street 2:
Practice Address - City:ACCOKEEK
Practice Address - State:MD
Practice Address - Zip Code:20607-3457
Practice Address - Country:US
Practice Address - Phone:301-675-1652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2021-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
MDR224501363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty