Provider Demographics
NPI:1689021792
Name:NDAMUKONG, MENTHOL (RN)
Entity Type:Individual
Prefix:
First Name:MENTHOL
Middle Name:
Last Name:NDAMUKONG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 MAPLE TREE DR APT 1K
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-8555
Mailing Address - Country:US
Mailing Address - Phone:410-948-0983
Mailing Address - Fax:
Practice Address - Street 1:302 MAPLE TREE DR APT 1K
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060-8555
Practice Address - Country:US
Practice Address - Phone:410-948-0983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR158288163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse