Provider Demographics
NPI:1689386385
Name:FONGANG, LIVINUS NGOH
Entity Type:Individual
Prefix:
First Name:LIVINUS
Middle Name:NGOH
Last Name:FONGANG
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 1:3801 KENILWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BLADENSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20710-2122
Mailing Address - Country:US
Mailing Address - Phone:240-825-6166
Mailing Address - Fax:
Practice Address - Street 1:3801 KENILWORTH AVE
Practice Address - Street 2:
Practice Address - City:BLADENSBURG
Practice Address - State:MD
Practice Address - Zip Code:20710-2122
Practice Address - Country:US
Practice Address - Phone:240-825-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide