Provider Demographics
NPI:1710247218
Name:GHOUMGA, MARIETTE CHRISTELLE
Entity Type:Individual
Prefix:
First Name:MARIETTE
Middle Name:CHRISTELLE
Last Name:GHOUMGA
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 1:14108 CASTLE BLVD
Mailing Address - Street 2:APT 302
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-4618
Mailing Address - Country:US
Mailing Address - Phone:240-374-2742
Mailing Address - Fax:
Practice Address - Street 1:14108 CASTLE BLVD
Practice Address - Street 2:APT 302
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-4618
Practice Address - Country:US
Practice Address - Phone:240-374-2742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG-520-585-115-577374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide