Provider Demographics
NPI:1689172710
Name:MVONDO, MIREILLE MEZAGUE
Entity Type:Individual
Prefix:
First Name:MIREILLE
Middle Name:MEZAGUE
Last Name:MVONDO
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 1:6733 NEW HAMPSHIRE AVE APT 907
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-2855
Mailing Address - Country:US
Mailing Address - Phone:240-704-1010
Mailing Address - Fax:
Practice Address - Street 1:6733 NEW HAMPSHIRE AVE APT 907
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-2855
Practice Address - Country:US
Practice Address - Phone:240-704-1010
Practice Address - Fax:240-704-1010
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1536035996303747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant