Provider Demographics
NPI:1629327911
Name:BERTHA, FONCHENALLA NGUAFAC
Entity Type:Individual
Prefix:
First Name:FONCHENALLA
Middle Name:NGUAFAC
Last Name:BERTHA
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 1:5917 CHERRYWOOD TER APT 205
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-4273
Mailing Address - Country:US
Mailing Address - Phone:240-595-8331
Mailing Address - Fax:
Practice Address - Street 1:5917 CHERRYWOOD TER APT 205
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-4273
Practice Address - Country:US
Practice Address - Phone:240-595-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-03
Last Update Date:2012-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide