Provider Demographics
NPI:1619302585
Name:GWANVOMA, STEPHEN BOBGA (HHA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BOBGA
Last Name:GWANVOMA
Suffix:
Gender:M
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 W KINGSWAY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-4925
Mailing Address - Country:US
Mailing Address - Phone:202-545-0935
Mailing Address - Fax:202-545-0176
Practice Address - Street 1:670 W KINGSWAY RD
Practice Address - Street 2:
Practice Address - City:MIDDLE RIVER
Practice Address - State:MD
Practice Address - Zip Code:21220-4925
Practice Address - Country:US
Practice Address - Phone:202-545-0935
Practice Address - Fax:202-545-0176
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide