Provider Demographics
NPI:1760098230
Name:MUKWE, QUEENTER
Entity Type:Individual
Prefix:
First Name:QUEENTER
Middle Name:
Last Name:MUKWE
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 1:1707 ARCOLA AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-2813
Mailing Address - Country:US
Mailing Address - Phone:240-970-2555
Mailing Address - Fax:
Practice Address - Street 1:1707 ARCOLA AVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-2813
Practice Address - Country:US
Practice Address - Phone:240-970-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC276776335251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC276776335Medicaid