Provider Demographics
NPI:1760730097
Name:FOMBOH, VIVIANE NGWOSUNGA
Entity Type:Individual
Prefix:
First Name:VIVIANE
Middle Name:NGWOSUNGA
Last Name:FOMBOH
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 1:5437 16TH AVENUE
Mailing Address - Street 2:APT 102
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782
Mailing Address - Country:US
Mailing Address - Phone:240-988-1708
Mailing Address - Fax:
Practice Address - Street 1:1818 NEW YORK AVENUE NE
Practice Address - Street 2:SUITE 228
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002
Practice Address - Country:US
Practice Address - Phone:202-832-8340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide