Provider Demographics
NPI:1689353815
Name:FONDU, MATHEW
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:
Last Name:FONDU
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 1:9633 UTICA PL
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5449
Mailing Address - Country:US
Mailing Address - Phone:240-899-0785
Mailing Address - Fax:
Practice Address - Street 1:2811 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3865
Practice Address - Country:US
Practice Address - Phone:202-894-6811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-14
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
DCRN1039373163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No251S00000XAgenciesCommunity/Behavioral Health