Provider Demographics
NPI:1790041077
Name:FANDIO MBAMI, MARCELLE A WANDJI (LPN)
Entity Type:Individual
Prefix:
First Name:MARCELLE
Middle Name:A WANDJI
Last Name:FANDIO MBAMI
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 L ST NW
Mailing Address - Street 2:SUITE 900
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20036-4201
Mailing Address - Country:US
Mailing Address - Phone:301-272-1973
Mailing Address - Fax:
Practice Address - Street 1:1707 L ST NW
Practice Address - Street 2:SUITE 900
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-4201
Practice Address - Country:US
Practice Address - Phone:202-829-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLPN1006917164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse