Provider Demographics
NPI:1609464445
Name:NICHODEMUS KUNGANG, MORFAW
Entity Type:Individual
Prefix:
First Name:MORFAW
Middle Name:
Last Name:NICHODEMUS KUNGANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4416 BURKES PROMISE DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4697
Mailing Address - Country:US
Mailing Address - Phone:240-486-7138
Mailing Address - Fax:
Practice Address - Street 1:4416 BURKES PROMISE DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-4697
Practice Address - Country:US
Practice Address - Phone:240-486-7138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC277698244Medicaid